A Simple Change That Makes Emergency Intubation Safer: Preoxygenating With Noninvasive Ventilation
When a critically ill adult needs a breathing tube, the minutes around intubation are some of the most dangerous in their care. Oxygen levels can fall quickly, and low oxygen (hypoxemia) during intubation raises the risk of cardiac arrest and death. Before intubation, teams give extra oxygen to build a reserve, a step called preoxygenation. A large 2024 trial in the New England Journal of Medicine, called PREOXI, tested whether a better way of preoxygenating could prevent dangerous drops in oxygen.
This summary is based on the published abstract. Read the abstract on PubMed
What the authors did
The trial ran at 24 emergency departments and intensive care units in the United States. Critically ill adults (18 or older) who needed tracheal intubation were randomly assigned to one of two preoxygenation methods:
- Noninvasive ventilation: a tight-fitting mask connected to a machine that delivers oxygen with pressure support.
- Oxygen mask: the standard approach.
The main outcome was hypoxemia during intubation, defined as an oxygen saturation below 85% at any point from the start of anesthesia until 2 minutes after the tube was placed.
What they found
The trial enrolled 1,301 patients.
- Less hypoxemia: low oxygen occurred in 9.1% of the noninvasive-ventilation group versus 18.5% of the oxygen-mask group, about half as often.
- Fewer cardiac arrests: cardiac arrest occurred in 1 patient (0.2%) with noninvasive ventilation versus 7 patients (1.1%) with an oxygen mask.
- No rise in aspiration: aspiration (stomach contents entering the lungs), a concern with mask ventilation, occurred in 0.9% versus 1.4%, a difference that was not statistically significant.
The authors conclude that, among critically ill adults undergoing intubation, preoxygenation with noninvasive ventilation led to less hypoxemia than an oxygen mask.
Limitations
The trial took place in emergency departments and intensive care units, so results may not apply directly to planned surgery in the operating room. Cardiac arrest was rare, so that comparison rests on small numbers. The abstract does not report which patients benefited most or longer-term outcomes such as survival.
Safety takeaways: how to apply it
For emergency, critical care and anesthesia teams
- Make noninvasive ventilation a default option for preoxygenation. For critically ill adults needing urgent intubation, this trial supports it over a standard oxygen mask.
- Build it into the airway checklist. Have the device, mask and settings ready before every emergency intubation so the step is not skipped under time pressure.
- Train the whole team. Nurses, respiratory therapists and physicians should all be comfortable setting up and monitoring noninvasive ventilation.
- Watch oxygen saturation continuously. Treat any fall toward low levels as a signal to pause and re-oxygenate.
- Keep aspiration in mind. The trial did not show an increase, but teams should stay alert to it and follow local protocols.
For hospitals and safety leaders
- Track hypoxemia during intubation as a safety measure. Measuring it shows whether new practices are working.
For patients and families
- Ask about the plan. If a loved one may need a breathing tube, it is reasonable to ask how the team prepares oxygen levels beforehand.
Reference
- Gibbs KW, Semler MW, Driver BE, Seitz KP, Stempek SB, Taylor C, et al; PREOXI Investigators and the Pragmatic Critical Care Research Group. Noninvasive ventilation for preoxygenation during emergency intubation. N Engl J Med. 2024 Jun;390(23):2165-2177. doi:10.1056/NEJMoa2313680. PMID: 38869091. PubMed: https://pubmed.ncbi.nlm.nih.gov/38869091/
Related: Monitored Anesthesia Care (MAC) for Pain Procedures
This article is educational information, not legal or medical advice.
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