Thread by @WellingtonICU

Another @wellingtonICU journal club. Nasal high-flow preoxygenation for endotracheal intubation in the critically ill patient: a randomized clinical trial
link.springer.com/article/10.100…

Aim: to compare preoxygenation with high-flow nasal cannulae (HFNC) and standard bag-mask oxygenation (SMO) in non-severely hypoxaemic patients during rapid-sequence intubation (RSI) in ICU

Primary outcome: median lowest pulse oximetry throughout intubation

Secondary outcomes: drop in SpO2, adverse events - severe (cardiac arrest/SpO2 <80, death, SBP<80mmHg, vasopressors started/increased 30%) or moderate, outcome in ICU

Seven French ICUs, 192 patients, April 2016-June 2017, 28 day follow up, randomized in 6 patient blocks, non-blinded, didn’t specify induction meds

Study of patients who were NOT severely hypoxaemic – required PaO2/FiO2 <200 within 4 hours before inclusion

Intervention: 4mins HFNC (Airvo 2, Fisher and Paykel) at 60L/min, FiO2 100%, 37deg and LEFT ON during intubation

Control: 4 mins SMO 15L/min disposable self-inflating resuscitator with reservoir bag manually held in place (ie two handed grip) and (obviously) REMOVED during intubation

Results: no difference in MEDIAN lowest pulse oximetry throughout intubation. But other statistically significant results…

HFNC group had fewer patients with SpO2 that fell below 95% (12% vs 23%) in the SMO group), and below 90% (6% vs 14%), and below 80% (2% vs 8%) during intubation

HFNC group also had fewer severe complications, despite having more patients who were “difficult intubations” (>10mins and/or 3 attempts or change of device) – 6% vs 16% in the SMO group, and fewer moderate complications – 0% vs 7%

SMO group were slightly faster to be intubated (1min vs 0.8min)

There is building evidence that supports apneic oxygenation in various forms, as described in a meta-analysis conducted by Lucas et al in Annals of Emergency Medicine October 2017: doi.org/10.1016/j.anne…

Apnoeic oxygenation is commonly applied for RSI in Emergency Departments, usually by conventional nasal cannula, an area which requires more study, as concluded by West and Williams in this study: doi.org/10.1016/j.anne…

OPTINIV study: Jaber et al in 2016 also showed that non-invasive ventilation for pre-oxygenation combined with HFNC throughout intubation raised the lowest SpO2 during intubation: doi: 10.1007/s00134-016-4588-9

Guitton et al have shown HFNC to be better than SMO in the prevention of complications in RSI in non-severely hypoxaemic patients in ICU, but also raise questions as to how much of this effect is due to apneic oxygenation.

More research needed!

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