Preoxygenation in the ICU

Tracheal intubation is a frequent and high-risk procedure in the intensive care unit (ICU). Unlike elective intubation in the operating room, ICU intubation is often performed under emergent conditions in physiologically unstable patients, leading to increased technical difficulty and higher complication rates. Among these, hypoxemia is particularly frequent and represents a major determinant of morbidity and mortality. Optimizing preoxygenation is therefore a cornerstone of safe airway management in critically ill patients. The aim of this review is to explore the advantages and limitations of each preoxygenation strategy and to provide clinicians with clear, practical guidance to optimize airway management in the ICU. Preoxygenation aims to increase oxygen reserves in order to prolong the duration of safe apnea. Conventional methods include high-flow oxygen delivery through a tightly fitted face mask, though efficacy depends on minimizing leaks. More advanced strategies include non-invasive ventilation (NIV), which improves both alveolar oxygen fraction and lung volume, and high-flow nasal cannula (HFNC), which additionally allows apneic oxygenation during intubation. Randomized controlled trials, including the recent PREOXY study, demonstrate the superiority of NIV over facemask preoxygenation in reducing peri-intubation desaturation, particularly in hypoxemic patients. HFNC is valuable when NIV is contraindicated, while combined approaches (NIV plus HFNC) may further enhance efficacy. Beyond technique, structured protocols and team organization are crucial to reduce complications. In conclusion, preoxygenation is an essential, patient-specific intervention that mitigates the risks of ICU intubation. Familiarity with available methods enables clinicians to tailor strategies, optimize oxygenation, and improve patient safety during this high-risk procedure.