Noninvasive Ventilation Preoxygenation Prior to Intubation: A Meta-Analysis of Randomized Trials

Tuesday, February 25, 2025

12:15pm – 1:15pm Eastern Time

Location: Connections Central Theater 1

MM

Mohamed Maali Mohamed, MD, MPH (he/him/his)

Disclosure(s): No relevant financial relationship(s) to disclose.
AS

Azib Shahid, MD

Pulmonary Critical care fellow
Saint Louis University

Disclosure information not submitted.
JP

John Peters, DO

Internal Medicine resident
Saint Louis University

Disclosure information not submitted.
EP

Edgar Theodore Polintan, MD

Internal Medicine resident
SSM Health

Disclosure information not submitted.
SK

Shawn Kim, DO

Intensivist
SSM Health Saint Louis University Hospital

Disclosure information not submitted.
KC

Kene Chukwuanu, MD

Emergency physician/Intensivist
SSM Health Saint Louis University Hospital

Disclosure information not submitted.

Disclosure(s):

Mohamed Maali G. Mohamed, MD, MPH: No relevant financial relationship(s) to disclose.

Introduction: Preoxygenation prior to emergent intubation is essential to minimize the risk of hypoxemia. Most critical care providers use oxygen (O2) face mask/non-rebreather (NRM) as a preoxygenation method. Despite that, hypoxemia is still unavoidable with detrimental consequences. Recently, Non-invasive ventilation (NIV) was investigated as a preoxygenation method and showed promising results. Therefore, we conducted this meta-analysis to evaluate and summarize the evidence of using NIV versus O2 face mask as preoxygenation method prior to emergent intubation.

Methods: We systematically searched multiple databases using prespecified search terms. We included only randomized controlled trials (RCT) comparing NIV to O2 face mask in patients undergoing emergent intubation in the ED/ICU setting. Primary outcome of interest was severe hypoxemia defined as SPO2 < 80%. Secondary outcomes included aspiration/new infiltrate rate, Mechanical Ventilation (MV) free days, ICU free days and hospital mortality. We calculated odd ratios (OR), mean differences (MD) and 95% confidence intervals (CI), via random effects model using RevMan 5.4 software.

Results: We identified and included three RCTs with a total of 1,555 (NIV=771, O2 mask=784). The patient mean age was 61±18 years, 39% were females. About half the patients (49%) had acute hypoxemic respiratory failure, 42% were diagnosed with sepsis and 18% had pneumonia. Two trials reported SAPS II score with mean of 48±16, one trial reported APACHE II score of 17±8. The mean SPO2 on enrollment was 95±5%. All trials implemented at least 3 minutes preoxygenation.
Our analysis showed that compared to O2 face mask, NIV arm had significantly lower rate of severe hypoxemia, [OR 0.31, 95% CI (0.12, 0.81), P=0.02, I2=39%], with no significant difference in aspiration/new infiltrate rate [OR 0.64, 95% CI (0.24, 1.66), P=0.36, I2=0]. No significant difference was detected regarding MV free days, ICU free day, and hospital mortality rate, [MD 1.40, 95% CI (-0.29, 3.10), P=0.10, I2=0], [MD 0.89, 95% CI (-0.63, 2.41), P=0.25, I2=0], [OR 0.88, 95% CI (0.65, 1.17), P=0.37, I2=17] respectively.

Conclusions: In patients undergoing emergency intubation in the ED/ICU, preoxygenation with NIV is superior to Oxygen face mask in reducing severe hypoxemia, with no increased risk of aspiration.