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A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation
Published on: January 17, 2011
Noninvasive Ventilation for Preoxygenation during Emergency Intubation.
Kevin W Gibbs1, Matthew W Semler1, Brian E Driver1
1From the Department of Medicine, Section of Pulmonary, Critical Care, Allergy, and Immunologic Diseases (K.W.G., J.A.P.), the Department of Anesthesiology, Section of Critical Care Medicine (J.P.G., J.K.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Wake Forest School of Medicine, Winston-Salem, NC; the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., K.P.S., A. Muhs, T.W.R., J.R., K.W., J.D.C.), the Departments of Emergency Medicine (W.H.S., B.D.L.) and Biostatistics (B.I.), and Vanderbilt Institute for Clinical and Translational Research (W.H.S., B.D.L.), Vanderbilt University Medical Center, Nashville; the Department of Emergency Medicine (B.E.D., M.E.P., S.J. Hansen) and the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J. Hansen), Hennepin County Medical Center, Minneapolis; the Department of Medicine, Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington (S.B.S., J.M.W.), and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.) - both in Massachusetts; the Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Ohio State University, Columbus (C.T., P.J.K.); the Department of Emergency Medicine (D.R.-A., S.G.S., C.W., S.A.T., V.S.B., A.A.G.) and the Center for COMBAT Research (V.S.B.), University of Colorado School of Medicine, and the Department of Medicine, Division of Pulmonary Sciences and Critical Care (N.R.A., P.D.S.), and the Department of Anesthesiology (J.C.B., S.G.S., N.K.), University of Colorado Anschutz Medical Campus - both in Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine, Baylor Scott and White Medical Center, Temple (H.D.W., S.A.G.), and U.S. Army Institute of Surgical Research (S.G.S., B.J.L.) and Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston (S.G.S., B.J.L.), and the 59th Medical Wing, Joint Base San Antonio-Lackland (B.J.L.), San Antonio - all in Texas; the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (S.G., M.R.W., D.W.R., D.B.P.), and the Departments of Emergency Medicine (M.R.W.) and Anesthesiology and Perioperative Medicine (A.B.B.), Heersink School of Medicine, University of Alabama at Birmingham, and Birmingham Veterans Affairs Medical Center, Pulmonary Section (D.W.R.) - both in Birmingham; the Department of Internal Medicine, Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, University of Iowa Carver College of Medicine, Iowa City (K.C.D., A.S.); the Department of Critical Care Medicine (A. Mohamed, L.A., V.B., A. Moskowitz, R.M.) and the Department of Medicine, Pulmonary Division (D.G.F.), Montefiore Einstein, Bronx, NY; the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health and Science University, Portland (A.K., G.A.); Our Lady of the Lake Regional Medical Center, Emergency Medicine Residency Program-Baton Rouge Campus (L.H.B., S.M.A.), and the Department of Pulmonary and Critical Care Medicine, Internal Medicine Residency Program-Baton Rouge Campus (J.E.W., C.B.T.), Louisiana State University Health Sciences Center School of Medicine-New Orleans, Baton Rouge; the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (S.J. Halliday, M.T.L.), and the Department of Anesthesia (M.T.L.), University of Wisconsin-Madison School of Medicine and Public Health, Madison; the Department of Emergency Medicine, Denver Health Medical Center, Denver (S.A.T.); and the University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine, New Orleans (D.R.J.).
Preoxygenation with noninvasive ventilation significantly reduced hypoxemia during tracheal intubation in critically ill adults compared to oxygen masks. This critical care intervention improves patient safety during airway management.
Area of Science:
- Critical Care Medicine
- Respiratory Therapy
- Emergency Medicine
Background:
- Hypoxemia during tracheal intubation poses significant risks, including cardiac arrest and death, in critically ill adults.
- The comparative effectiveness of preoxygenation methods, specifically noninvasive ventilation versus oxygen masks, for preventing hypoxemia during intubation remains unclear.
Purpose of the Study:
- To evaluate the incidence of hypoxemia during tracheal intubation in critically ill adults.
- To compare the efficacy of preoxygenation using noninvasive ventilation against preoxygenation with an oxygen mask.
Main Methods:
- A multicenter, randomized trial involving 1301 critically ill adults undergoing tracheal intubation.
- Participants were assigned to receive preoxygenation via either noninvasive ventilation or an oxygen mask.
- The primary outcome was defined as oxygen saturation below 85% from anesthesia induction to 2 minutes post-intubation.
Main Results:
- Hypoxemia occurred in 9.1% of patients in the noninvasive-ventilation group versus 18.5% in the oxygen-mask group (P<0.001).
- The noninvasive-ventilation group experienced a significantly lower incidence of hypoxemia (-9.4 percentage points).
- Cardiac arrest rates were lower in the noninvasive-ventilation group (0.2% vs. 1.1%).
Conclusions:
- Preoxygenation with noninvasive ventilation is more effective than oxygen masks in preventing hypoxemia during tracheal intubation in critically ill adults.
- This finding suggests noninvasive ventilation as a preferred strategy for preoxygenation in this patient population.
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