Avoiding Hypoxemia During Intubation

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Gibbs KW, Semler MW, Driver BE, et al. Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med 2024;390(23):2165–77.

Background

More than 1.5 million critically ill adults undergo tracheal intubation each year in the United States. Hypoxemia is a common and serious complication during tracheal intubation in critically ill adults, occurring up to 10-20% of intubations in the emergency department (ED) or intensive care unit (ICU). Hypoxemia increases the risk of cardiac arrest and death. The effect of preoxygenation with noninvasive ventilation, as compared with preoxygenation with an oxygen mask, on the incidence of hypoxemia during tracheal intubation is uncertain. There have been prior small trials gave conflicting results regarding the benefit of noninvasive ventilation (NIV) over oxygen masks for preoxygenation. This study was done to evaluate whether using noninvasive ventilation for preoxygenation, compared to an oxygen mask, reduces the incidence of hypoxemia during tracheal intubation in critically ill adults.

Study Design

This pragmatic, multicenter, unblinded, randomized, parallel-group trial was conducted in 24 sites (7 ED and 17 ICUs) at 15 different medical centers. Eligible patients included critically ill adults undergoing tracheal intubation involving the use of sedation and laryngoscope. Patients were excluded if they were pregnant, incarcerated, already on positive-pressure ventilation (PPV), apneic, or had immediate need of intubation that did not allow for randomization into the trial. There were a total of 1301 adults that underwent randomization. The primary outcome measured was hypoxemia during intubation (oxygen saturation <85%). The secondary outcome was lowest oxygen saturation, hypotension, vasopressor use, or cardiac arrest. Safety outcomres included aspiration.

Results

  • Primary Outcome:

    • Hypoxemia occurred in 9.1% (NIV group) vs. 18.5% (OM group).

    • Absolute risk reduction: −9.4 percentage points (95% CI: −13.2 to −5.6; P<0.001).

  • Secondary Outcomes:

    • Median lowest oxygen saturation: 99% (NIV) vs. 97% (OM).

    • Cardiac arrest: 0.2% (NIV) vs. 1.1% (OM).

    • Aspiration: 0.9% (NIV) vs. 1.4% (OM).

  • Subgroup Findings: Benefit of NIV was more pronounced in patients with higher body mass index.

Limitations

  • Excluded Populations: Patients already on positive-pressure ventilation, those at high aspiration risk, or requiring urgent intubation.

  • Unblinded Design: Clinicians and observers were aware of group assignments.

  • Generalizability: Results may not apply to all critical care settings, especially where equipment or personnel are limited.

Take-Home Points

  • Preoxygenation with NIV significantly reduces hypoxemia during emergency tracheal intubation compared to an oxygen mask.

  • No significant increase in aspiration risk with NIV.

Authorship

  • Written by: Julius de Castro, MD, PGY-3, University of Cincinnati Department of Emergency Medicine

  • Audio Editing: Anita Goel, MD, Adjuct Assistant Professor, University of Cincinnati Department of Emergency Medicine

  • Editing and Posting by Jeffery Hill MD, MEd, Associate Professor, University of Cincinnati Department of Emergency Medicine

  • Cite As: de Castro, J. Hill, J., Goel, A. Avoiding Hypoxemia During Intubation. TamingtheSRU. www.tamingthesru.com/blog/journal-club/hypoxemia-NIPPV. 5/27/2025