Bridging the Oxygenation Gap: A Dual-Modality Approach in Severe Acute Respiratory Distress Syndrome

Patients suffering from severe acute respiratory distress syndrome (ARDS) are at an increased risk for peri-intubation complications due to profound hypoxemia, poor lung compliance, and intrapulmonary shunting. Standard preoxygenation methods often leave patients vulnerable to rapid desaturation during apnea. A dual-modality preoxygenation strategy combining noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC) has emerged as a physiologically sound approach to tackle this challenge. We report a case of a 46-year-old gentleman with no known comorbidities who presented with severe dyspnea and respiratory failure secondary to necrotizing pneumonia. Despite maximal oxygenation via a non-rebreather mask, peripheral capillary oxygen saturation (SpO₂) remained below 90%, necessitating prompt endotracheal intubation. Preoxygenation was achieved with NIV using a bilevel positive airway pressure (BiPAP) device, followed by HFNC at 60 L/min during induction. The patient maintained a SpO₂ > 94% throughout the peri-intubation period without any complications. This case highlights that combining NIV and HFNC can effectively bridge the oxygenation gap in severe ARDS, minimizing peri intubation hypoxemia, the severe oxygen desaturation during intubation, and enhancing patient safety during emergent airway management. This approach could be considered in profoundly hypoxemic patients requiring intubation in an emergency setting.