bag mask ventilation between induction and intubation improved oxygenation

  • PreVent study showed bag mask ventilation improved oxygenation between induction and intubation compared to RSI.
  • However, this did not improve first pass success1

This patient is experiencing acute hypoxemic respiratory failure and has marginal oxygenation with use of a high-flow nasal cannula. Given his marginal oxygenation, he is at increased risk for experiencing hypoxemia as a complication of the tracheal intubation procedure. Up to 40% of patients experience hypoxemia during tracheal intubation, with 20% experiencing severe hypoxemia (defined as lowest SpO2 during the intubation <80%). Lower SpO2 at the time of intubation is one of the biggest risk factors for hypoxemia during tracheal intubation. In the PreVent randomized controlled trial, bag-mask ventilation between administration of induction medications and laryngoscopy reduced the risk of both hypoxemia (SpO2 <90%) and severe hypoxemia (SpO2 <80%) (choice B is correct). Usually, bag-mask ventilation is performed in conjunction with a nasal trumpet or oral airway. Despite concerns over potentially inducing aspiration with bag-mask ventilation, the rates of aspiration were similar between the bag-mask ventilation and straight rapid sequence intubation groups.

The PREOXI study demonstrated that extending this positive pressure ventilation into the preinduction phase of the procedure may further reduce the risk for severe hypoxemia. Data suggest that a technique called “delayed sequence intubation”—namely, administering procedural sedation before attempts at preoxygenation, followed by a neuromuscular agent after a few minutes of preoxygenation, may decrease the risk of severe hypoxemia in patients who are not cooperative or who have altered mental status.23456

Footnotes

  1. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults ↩

  2. SEEK Questionnaires ↩

  3. Casey JD, Janz DR, Russell DW, et al; PreVent Investigators and the Pragmatic Critical Care Research Group. Bag-mask ventilation during tracheal intubation of critically ill adults. N Engl J Med. 2019;380(9):811-821. PubMed ↩

  4. Gibbs KW, Ginde AA, Prekker ME, et al; PREOXI Investigators and the Pragmatic Critical Care Research Group. Protocol and statistical analysis plan for the PREOXI trial of preoxygenation with noninvasive ventilation vs oxygen mask in critically ill adults. CHEST Crit Care. 2023;1(2):100014. ↩

  5. Gibbs KW, Semler MW, Driver BE, et al; PREOXI Investigators and the Pragmatic Critical Care Research Group. Noninvasive ventilation for preoxygenation during emergency intubation. N Engl J Med. Published online June 13, 2024. PubMed ↩

  6. Russotto V, Myatra SN, Laffey JG, et al; INTUBE Study Investigators. Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries. JAMA. 2021;325(12):1164-1172. PubMed ↩