Oxygen supplementation in pediatric sedation—prospective, multicenter, randomized controlled trial

Children undergoing moderate to deep sedation for diagnostic and therapeutic procedures are susceptible to hypoxemia because of their anatomical and physiologic features. However, optimal oxygen administration methods are unclear. This study aimed to evaluate the efficacy of oxygen supplementation during sedation using either low-flow or high-flow nasal cannula. This prospective, multicenter randomized controlled trial included children (younger than 18 yr) undergoing moderate to deep sedation. The participants were randomly assigned to three groups as follows: (1) control (no oxygen), (2) low-flow (2 to 6 l/min oxygen via nasal cannula), and (3) high-flow (oxygen administration via high-flow nasal cannula with a flow rate of 2 l/kg and 50% fraction of inspired oxygen). The primary outcome was hypoxemia incidence (saturation of peripheral oxygen, oxygen saturation measured by pulse oximetry 95% or less for more than 5 s). Secondary outcomes included oxygen saturation measured by pulse oximetry less than 90%, rescue interventions, and sedation-related complications. Between-group differences were compared using a logistic regression model. A total of 253 participants were randomized, with 250 completing the study. Hypoxemia occurred in 27.6% of participants in the control group, 7.2% in the low-flow group, and 1.2% in the high-flow group ( P < 0.001). The odds of hypoxemia in the low-flow and high-flow groups were lower than that in the control group (odds ratio [OR], 0.184; 95% CI, 0.067 to 0.503; P = 0.001 for low-flow; OR, 0.026; 95% CI, 0.003 to 0.207; P < 0.001 for high-flow). However, hypoxemia incidence of the high-flow group was not statistically lower than the low-flow group (OR, 0.143; 95% CI, 0.017 to 1.245; P = 0.078). Rescue interventions were conducted more frequently in the control group (52.9%) than in the low-flow (10.8%) and high-flow (3.6%) groups ( P < 0.001). Sedation-related complications such as desaturation and apnea were lower in the low-flow and high-flow groups than in the control group ( P < 0.001). Routine oxygen supplementation prevents hypoxemia during pediatric moderate and deep sedation. Low-flow oxygen can be a reasonable choice as it effectively reduces hypoxemia while being more cost-effective and widely accessible than high-flow oxygen.