<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT03240614</url>
  </required_header>
  <id_info>
    <org_study_id>POET1</org_study_id>
    <nct_id>NCT03240614</nct_id>
  </id_info>
  <brief_title>PreOxygenation for EndoTracheal Intubations</brief_title>
  <acronym>POET</acronym>
  <official_title>PreOxygenation for Airway Management: High Flow Versus Conventional Preoxygenation Therapy</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>Nova Scotia Health Authority</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
  </sponsors>
  <source>Nova Scotia Health Authority</source>
  <oversight_info>
    <has_dmc>No</has_dmc>
    <is_fda_regulated_drug>No</is_fda_regulated_drug>
    <is_fda_regulated_device>No</is_fda_regulated_device>
    <is_us_export>No</is_us_export>
  </oversight_info>
  <brief_summary>
    <textblock>
      Hypoxemia is a life threatening complication during emergency airway management. Despite&#xD;
      advances in technology and training, hypoxemia still occurs in up to a quarter of all&#xD;
      intubations placing patients at high risk for damage to vital organs and death. A key method&#xD;
      in the prevention of hypoxemia is known as preoxygenation which has been shown to decrease&#xD;
      the incidence of hypoxemia. Currently there are two conventional methods for preoxygenation&#xD;
      in the literature, however recently a new method has been described as a possible alternative&#xD;
      method. What is unclear in the literature is if one modality is superior than the other for&#xD;
      preoxygenation. The goal of this interventional study is to determine if one method of&#xD;
      preoxygenation is superior to the other. This is a 3 arm interventional cross over designed&#xD;
      study comparing three interventional methods for preoxygenation. Non-rebreather mask,&#xD;
      bag-valve mask and high flow nasal cannulae.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      In emergency and critical care medicine, one of the most common incidences of severe&#xD;
      hypoxemia occurs during the process of endotracheal intubations. Endotracheal intubations,&#xD;
      also known as insertion of a breathing tube, is a life saving technique used in medicine to&#xD;
      help maintain oxygen delivery, to protect lungs from injury, for patients to safely undergo&#xD;
      anesthesia for surgeries, as well as to help rest critically ill patients to allow their&#xD;
      bodies time to recover. Despite advances in the field of medicine, the process of placing a&#xD;
      breathing tube in emergency situations is still associated with an increase risk of hypoxemia&#xD;
      up to 26.7%. This places patients at significant risk for cardiac dysrhythmia, brain damage&#xD;
      and hemodynamic decompensation which may ultimately result in death. A UK national review of&#xD;
      emergency intubations identified hypoxemia as a cause of death in 50% of intensive care&#xD;
      intubations and 27% of Emergency Department intubations. Therefore, it is imperative to&#xD;
      improve and develop methods to minimize hypoxemia during airway management.&#xD;
&#xD;
      A vital component used to minimize the risk of hypoxemia during endotracheal intubations is&#xD;
      preoxygenation. Preoxygenation is a method to to prolong the time to oxygen desaturation by&#xD;
      replacing the lung volume with 100% oxygen compared to 21% oxygen (room air) through the&#xD;
      administration of supplemental oxygen. This increases the reservoir of oxygen in the lungs&#xD;
      that the body can use to prolong their time to desaturation. Studies have shown a good&#xD;
      preoxygenation technique can increase the time to oxygen desaturation from 0.6 min to 8 min&#xD;
      in a non obese patient. This remarkable impact at preventing hypoxemia has made&#xD;
      preoxygenation the gold standard to minimize hypoxemia during airway management.&#xD;
&#xD;
      Historically preoxygenation with bag-valve-mask ventilation (BVM) and an oxygen&#xD;
      non-rebreather mask has been the standard for preoxygenation. Recently, the use of high flow&#xD;
      nasal cannulaes have been used for preoxygenation however it is unclear in the literature if&#xD;
      one provides a superior preoxygenation compared to another. In an effort to determine the&#xD;
      best preoxygenation modality for airway management, the investigators will conduct a 3 arm&#xD;
      interventional crossover designed study to compare preoxygenation using a non-rebreather&#xD;
      mask, BVM and HFNC in 150 patients. To determine which modality provides the best&#xD;
      preoxygenation, arterial blood gases will be taken after each intervention and compared&#xD;
      against each other.&#xD;
&#xD;
      Given the high propensity for hypoxemia during airway management in the obese and disease&#xD;
      lung population, this protocol will have specific groups based on their BMI (&lt;30, 30-35 and&#xD;
      &gt;35) as well as the presence of lung disease based upon their PaO2/FiO2 ratio (&lt; 300 lung&#xD;
      disease or &gt;300 no lung disease).&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Unknown status</overall_status>
  <last_known_status>Recruiting</last_known_status>
  <start_date type="Actual">July 30, 2018</start_date>
  <completion_date type="Anticipated">April 14, 2022</completion_date>
  <primary_completion_date type="Anticipated">December 15, 2021</primary_completion_date>
  <phase>N/A</phase>
  <study_type>Interventional</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <allocation>Non-Randomized</allocation>
    <intervention_model>Crossover Assignment</intervention_model>
    <intervention_model_description>Will test preoxygenation using High Flow Nasal Cannulae, Non-rebreather mask and Bag-Valve-Mask</intervention_model_description>
    <primary_purpose>Treatment</primary_purpose>
    <masking>Single (Outcomes Assessor)</masking>
    <masking_description>Interventions will be labeled using a Letter key so the analysis of the dataset by our statistician will be blinded</masking_description>
  </study_design_info>
  <primary_outcome>
    <measure>PaO2</measure>
    <time_frame>An ABG will be taken 3 min after preoxygenation in the NRB and HFNC group. The ABG will be taken once the ETO2 is &gt;85% in the BVM group. Pooled data will be collected at the conclusion of the study to be analyzed within 6 months of completion.</time_frame>
    <description>Partial pressure of arterial oxygen</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>PaCO2</measure>
    <time_frame>An ABG will be taken 3 min after preoxygenation in the NRB and HFNC group. The ABG will be taken once the ETO2 is &gt;85% in the BVM group. Pooled data will be collected at the conclusion of the study to be analyzed within 6 months of completion.</time_frame>
    <description>Partial pressure of arterial carbon dioxide</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Patient comfort</measure>
    <time_frame>At the conclusion of all interventions the data will be collected on each individual participant. Pooled data will be collected at the conclusion of the study to be analyzed within 6 months of completion.</time_frame>
    <description>Numeric scoring of patient comfort for each intervention</description>
  </secondary_outcome>
  <number_of_arms>6</number_of_arms>
  <enrollment type="Anticipated">150</enrollment>
  <condition>Intubation Complication</condition>
  <condition>Preoxygenation</condition>
  <condition>Hypoxemia</condition>
  <arm_group>
    <arm_group_label>BMI &lt;30 no lung disease</arm_group_label>
    <arm_group_type>Active Comparator</arm_group_type>
    <description>Patients with a BMI &lt;30 with no lung disease</description>
  </arm_group>
  <arm_group>
    <arm_group_label>BMI &lt;30 with lung disease</arm_group_label>
    <arm_group_type>Active Comparator</arm_group_type>
    <description>Patients with a BMI &lt;30 with lung disease</description>
  </arm_group>
  <arm_group>
    <arm_group_label>BMI 30-35 with no lung disease</arm_group_label>
    <arm_group_type>Active Comparator</arm_group_type>
    <description>Patients with a BMI between 30 and 35 with no lung disease</description>
  </arm_group>
  <arm_group>
    <arm_group_label>BMI 30-35 with lung disease</arm_group_label>
    <arm_group_type>Active Comparator</arm_group_type>
    <description>Patients with a BMI between 30 and 35 with lung disease</description>
  </arm_group>
  <arm_group>
    <arm_group_label>BMI &gt;35 with no lung disease</arm_group_label>
    <arm_group_type>Active Comparator</arm_group_type>
    <description>Patients with a BMI&gt; 35 with no lung disease</description>
  </arm_group>
  <arm_group>
    <arm_group_label>BMI &gt;35 with lung disease</arm_group_label>
    <arm_group_type>Active Comparator</arm_group_type>
    <description>Patients with a BMI&gt; 35 with lung disease</description>
  </arm_group>
  <intervention>
    <intervention_type>Device</intervention_type>
    <intervention_name>Non-rebreather oxygen mask</intervention_name>
    <description>This intervention will be preoxygenation using a Non-rebreather that will be placed upon the participant for preoxygenation. The oxygen flow will be set at 60 L/min and the participant will be preoxygenated for a total of 3 minutes. After 3 minutes, an ABG will be taken and labeled as Intervention A.</description>
    <arm_group_label>BMI 30-35 with lung disease</arm_group_label>
    <arm_group_label>BMI 30-35 with no lung disease</arm_group_label>
    <arm_group_label>BMI &lt;30 no lung disease</arm_group_label>
    <arm_group_label>BMI &lt;30 with lung disease</arm_group_label>
    <arm_group_label>BMI &gt;35 with lung disease</arm_group_label>
    <arm_group_label>BMI &gt;35 with no lung disease</arm_group_label>
  </intervention>
  <intervention>
    <intervention_type>Device</intervention_type>
    <intervention_name>Bag-valve-mask</intervention_name>
    <description>This intervention will be preoxygenation using a BVM apparatus for preoxygenation for 3 minutes. At the end of 3 minutes an ABG will be obtained.</description>
    <arm_group_label>BMI 30-35 with lung disease</arm_group_label>
    <arm_group_label>BMI 30-35 with no lung disease</arm_group_label>
    <arm_group_label>BMI &lt;30 no lung disease</arm_group_label>
    <arm_group_label>BMI &lt;30 with lung disease</arm_group_label>
    <arm_group_label>BMI &gt;35 with lung disease</arm_group_label>
    <arm_group_label>BMI &gt;35 with no lung disease</arm_group_label>
  </intervention>
  <intervention>
    <intervention_type>Device</intervention_type>
    <intervention_name>High Flow Nasal Cannulae</intervention_name>
    <description>This intervention will be preoxygenation using High Flow Nasal Cannulaes at an FiO2 of 100%. The oxygen flow will be set at 60 L/min and the participant will be preoxygenated for a total of 3 minutes. After the 3 minutes, an ABG will be taken and labeled as Intervention C.</description>
    <arm_group_label>BMI 30-35 with lung disease</arm_group_label>
    <arm_group_label>BMI 30-35 with no lung disease</arm_group_label>
    <arm_group_label>BMI &lt;30 no lung disease</arm_group_label>
    <arm_group_label>BMI &lt;30 with lung disease</arm_group_label>
    <arm_group_label>BMI &gt;35 with lung disease</arm_group_label>
    <arm_group_label>BMI &gt;35 with no lung disease</arm_group_label>
  </intervention>
  <eligibility>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
          -  Patients with a pre-existing arterial line&#xD;
&#xD;
          -  Age &gt; 18&#xD;
&#xD;
          -  Able to provide consent&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
          -  Acute respiratory distress Defined as RR &gt;30, Baseline oxygen requirements &gt;50%,&#xD;
             current use of High Flow Nasal Cannulae or Non-invasive ventilation for respiratory&#xD;
             support&#xD;
&#xD;
          -  Decreased level of consciousness GCS &lt;13&#xD;
&#xD;
          -  Possible exclusion if the allocation to prespecified groups are filled&#xD;
&#xD;
          -  Contraindication for high oxygen therapy Severe Chronic Obstructive Pulmonary Disease&#xD;
             with documented CO2 retention based on outpatient ABG History of Bleomycin use&#xD;
&#xD;
          -  Significant hemodynamic instability Lactate &gt; 3 mmol/L Norepinephrine dose &gt;0.2&#xD;
             mcg/kg/min or equivalent dose of other vasopressors&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>18 Years</minimum_age>
    <maximum_age>N/A</maximum_age>
    <healthy_volunteers>Accepts Healthy Volunteers</healthy_volunteers>
  </eligibility>
  <overall_contact>
    <last_name>Edmund Tan, MD</last_name>
    <phone>902-473-4455</phone>
    <email>cetan@dal.ca</email>
  </overall_contact>
  <location>
    <facility>
      <name>QEII Health Sciences Centre</name>
      <address>
        <city>Halifax</city>
        <state>Nova Scotia</state>
        <zip>B3H 3G1</zip>
        <country>Canada</country>
      </address>
    </facility>
    <status>Recruiting</status>
    <contact>
      <last_name>Chong-How E Tan</last_name>
      <phone>9024888082</phone>
      <email>cetan@dal.ca</email>
    </contact>
  </location>
  <location_countries>
    <country>Canada</country>
  </location_countries>
  <reference>
    <citation>Gebremedhn EG, Mesele D, Aemero D, Alemu E. The incidence of oxygen desaturation during rapid sequence induction and intubation. World J Emerg Med. 2014;5(4):279-85. doi: 10.5847/wjem.j.issn.1920-8642.2014.04.007.</citation>
    <PMID>25548602</PMID>
  </reference>
  <reference>
    <citation>Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011 May;106(5):632-42. doi: 10.1093/bja/aer059. Epub 2011 Mar 29.</citation>
    <PMID>21447489</PMID>
  </reference>
  <reference>
    <citation>Tanoubi I, Drolet P, Donati F. Optimizing preoxygenation in adults. Can J Anaesth. 2009 Jun;56(6):449-66. doi: 10.1007/s12630-009-9084-z. Epub 2009 Apr 28.</citation>
    <PMID>19399574</PMID>
  </reference>
  <reference>
    <citation>Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012 Mar;59(3):165-75.e1. doi: 10.1016/j.annemergmed.2011.10.002. Epub 2011 Nov 3.</citation>
    <PMID>22050948</PMID>
  </reference>
  <verification_date>March 2021</verification_date>
  <study_first_submitted>August 1, 2017</study_first_submitted>
  <study_first_submitted_qc>August 2, 2017</study_first_submitted_qc>
  <study_first_posted type="Actual">August 7, 2017</study_first_posted>
  <last_update_submitted>March 8, 2021</last_update_submitted>
  <last_update_submitted_qc>March 8, 2021</last_update_submitted_qc>
  <last_update_posted type="Actual">March 9, 2021</last_update_posted>
  <responsible_party>
    <responsible_party_type>Principal Investigator</responsible_party_type>
    <investigator_affiliation>Dalhousie University</investigator_affiliation>
    <investigator_full_name>Edmund Tan</investigator_full_name>
    <investigator_title>Assistant Professor</investigator_title>
  </responsible_party>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Hypoxia</mesh_term>
  </condition_browse>
  <patient_data>
    <sharing_ipd>Undecided</sharing_ipd>
  </patient_data>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT03240614
org study id: POET1
nct id: NCT03240614
lead sponsor: 
has dmc: No
is fda regulated drug: No
is fda regulated device: No
is us export: No
Hypoxemia is a life threatening complication during emergency airway management. Despite
      advances in technology and training, hypoxemia still occurs in up to a quarter of all
      intubations placing patients at high risk for damage to vital organs and death. A key method
      in the prevention of hypoxemia is known as preoxygenation which has been shown to decrease
      the incidence of hypoxemia. Currently there are two conventional methods for preoxygenation
      in the literature, however recently a new method has been described as a possible alternative
      method. What is unclear in the literature is if one modality is superior than the other for
      preoxygenation. The goal of this interventional study is to determine if one method of
      preoxygenation is superior to the other. This is a 3 arm interventional cross over designed
      study comparing three interventional methods for preoxygenation. Non-rebreather mask,
      bag-valve mask and high flow nasal cannulae.
In emergency and critical care medicine, one of the most common incidences of severe
      hypoxemia occurs during the process of endotracheal intubations. Endotracheal intubations,
      also known as insertion of a breathing tube, is a life saving technique used in medicine to
      help maintain oxygen delivery, to protect lungs from injury, for patients to safely undergo
      anesthesia for surgeries, as well as to help rest critically ill patients to allow their
      bodies time to recover. Despite advances in the field of medicine, the process of placing a
      breathing tube in emergency situations is still associated with an increase risk of hypoxemia
      up to 26.7%. This places patients at significant risk for cardiac dysrhythmia, brain damage
      and hemodynamic decompensation which may ultimately result in death. A UK national review of
      emergency intubations identified hypoxemia as a cause of death in 50% of intensive care
      intubations and 27% of Emergency Department intubations. Therefore, it is imperative to
      improve and develop methods to minimize hypoxemia during airway management.

      A vital component used to minimize the risk of hypoxemia during endotracheal intubations is
      preoxygenation. Preoxygenation is a method to to prolong the time to oxygen desaturation by
      replacing the lung volume with 100% oxygen compared to 21% oxygen (room air) through the
      administration of supplemental oxygen. This increases the reservoir of oxygen in the lungs
      that the body can use to prolong their time to desaturation. Studies have shown a good
      preoxygenation technique can increase the time to oxygen desaturation from 0.6 min to 8 min
      in a non obese patient. This remarkable impact at preventing hypoxemia has made
      preoxygenation the gold standard to minimize hypoxemia during airway management.

      Historically preoxygenation with bag-valve-mask ventilation (BVM) and an oxygen
      non-rebreather mask has been the standard for preoxygenation. Recently, the use of high flow
      nasal cannulaes have been used for preoxygenation however it is unclear in the literature if
      one provides a superior preoxygenation compared to another. In an effort to determine the
      best preoxygenation modality for airway management, the investigators will conduct a 3 arm
      interventional crossover designed study to compare preoxygenation using a non-rebreather
      mask, BVM and HFNC in 150 patients. To determine which modality provides the best
      preoxygenation, arterial blood gases will be taken after each intervention and compared
      against each other.

      Given the high propensity for hypoxemia during airway management in the obese and disease
      lung population, this protocol will have specific groups based on their BMI (<30, 30-35 and
      >35) as well as the presence of lung disease based upon their PaO2/FiO2 ratio (< 300 lung
      disease or >300 no lung disease).
allocation: Non-Randomized
intervention model: Crossover Assignment
intervention model description: Will test preoxygenation using High Flow Nasal Cannulae, Non-rebreather mask and Bag-Valve-Mask
primary purpose: Treatment
masking: Single (Outcomes Assessor)
masking description: Interventions will be labeled using a Letter key so the analysis of the dataset by our statistician will be blinded
measure: PaO2
time frame: An ABG will be taken 3 min after preoxygenation in the NRB and HFNC group. The ABG will be taken once the ETO2 is >85% in the BVM group. Pooled data will be collected at the conclusion of the study to be analyzed within 6 months of completion.
description: Partial pressure of arterial oxygen
measure: PaCO2
time frame: An ABG will be taken 3 min after preoxygenation in the NRB and HFNC group. The ABG will be taken once the ETO2 is >85% in the BVM group. Pooled data will be collected at the conclusion of the study to be analyzed within 6 months of completion.
description: Partial pressure of arterial carbon dioxide
measure: Patient comfort
time frame: At the conclusion of all interventions the data will be collected on each individual participant. Pooled data will be collected at the conclusion of the study to be analyzed within 6 months of completion.
description: Numeric scoring of patient comfort for each intervention
arm group label: BMI <30 no lung disease
arm group type: Active Comparator
description: Patients with a BMI <30 with no lung disease
arm group label: BMI <30 with lung disease
arm group type: Active Comparator
description: Patients with a BMI <30 with lung disease
arm group label: BMI 30-35 with no lung disease
arm group type: Active Comparator
description: Patients with a BMI between 30 and 35 with no lung disease
arm group label: BMI 30-35 with lung disease
arm group type: Active Comparator
description: Patients with a BMI between 30 and 35 with lung disease
arm group label: BMI >35 with no lung disease
arm group type: Active Comparator
description: Patients with a BMI> 35 with no lung disease
arm group label: BMI >35 with lung disease
arm group type: Active Comparator
description: Patients with a BMI> 35 with lung disease
intervention type: Device
intervention name: Non-rebreather oxygen mask
description: This intervention will be preoxygenation using a Non-rebreather that will be placed upon the participant for preoxygenation. The oxygen flow will be set at 60 L/min and the participant will be preoxygenated for a total of 3 minutes. After 3 minutes, an ABG will be taken and labeled as Intervention A.
arm group label: BMI 30-35 with lung disease
arm group label: BMI 30-35 with no lung disease
arm group label: BMI <30 no lung disease
arm group label: BMI <30 with lung disease
arm group label: BMI >35 with lung disease
arm group label: BMI >35 with no lung disease
intervention type: Device
intervention name: Bag-valve-mask
description: This intervention will be preoxygenation using a BVM apparatus for preoxygenation for 3 minutes. At the end of 3 minutes an ABG will be obtained.
arm group label: BMI 30-35 with lung disease
arm group label: BMI 30-35 with no lung disease
arm group label: BMI <30 no lung disease
arm group label: BMI <30 with lung disease
arm group label: BMI >35 with lung disease
arm group label: BMI >35 with no lung disease
intervention type: Device
intervention name: High Flow Nasal Cannulae
description: This intervention will be preoxygenation using High Flow Nasal Cannulaes at an FiO2 of 100%. The oxygen flow will be set at 60 L/min and the participant will be preoxygenated for a total of 3 minutes. After the 3 minutes, an ABG will be taken and labeled as Intervention C.
arm group label: BMI 30-35 with lung disease
arm group label: BMI 30-35 with no lung disease
arm group label: BMI <30 no lung disease
arm group label: BMI <30 with lung disease
arm group label: BMI >35 with lung disease
arm group label: BMI >35 with no lung disease
criteria: 
gender: All
minimum age: 18 Years
maximum age: N/A
healthy volunteers: Accepts Healthy Volunteers
last name: Edmund Tan, MD
phone: 902-473-4455
email: cetan@dal.ca
facility: 
status: Recruiting
contact: 
country: Canada
citation: Gebremedhn EG, Mesele D, Aemero D, Alemu E. The incidence of oxygen desaturation during rapid sequence induction and intubation. World J Emerg Med. 2014;5(4):279-85. doi: 10.5847/wjem.j.issn.1920-8642.2014.04.007.
PMID: 25548602
citation: Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011 May;106(5):632-42. doi: 10.1093/bja/aer059. Epub 2011 Mar 29.
PMID: 21447489
citation: Tanoubi I, Drolet P, Donati F. Optimizing preoxygenation in adults. Can J Anaesth. 2009 Jun;56(6):449-66. doi: 10.1007/s12630-009-9084-z. Epub 2009 Apr 28.
PMID: 19399574
citation: Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012 Mar;59(3):165-75.e1. doi: 10.1016/j.annemergmed.2011.10.002. Epub 2011 Nov 3.
PMID: 22050948
responsible party type: Principal Investigator
investigator affiliation: Dalhousie University
investigator full name: Edmund Tan
investigator title: Assistant Professor
mesh term: Hypoxia
sharing ipd: Undecided