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PREOXI RCT – Preoxygenation with Noninvasive Ventilation vs. Non-rebreather Mask

June 14, 2024

Written by Clay Smith

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Noninvasive ventilation (NIV) was superior to standard non-rebreather (NRB) oxygen mask for preoxygenation of critically ill, adult ED or ICU patients requiring intubation, with a NNT of 11 to prevent 1 episode of hypoxemia <85%.

PREOXI-genation takes a step forward
PREOXI was a multicenter, unblinded RCT with 1,301 critically ill, adult ED and ICU patients requiring intubation and compared two preoxygenation strategies: NIV (bilevel positive airway pressure, 10 cm H2O inspiratory pressure/ 5 cm H2O end-expiratory pressure at 100% O2) vs. oxygen mask (100% NRB, at least 15 L/min) for 3 minutes before induction. For the primary outcome of SpO2 <85% between induction and 2 minutes after intubation, hypoxemia occurred in 57/624 (9.1%) in the NIV group vs. 118/637 (18.5%) in the NRB mask group (difference -9.4%; 95%CI -13.2 to -5.6, p<0.001); NNT = 11. Cardiac arrest occurred in one patient (0.2%) in the NIV group and 7 patients (1.1%) in the NRB mask group (difference -0.9%; 95%CI -1.8 to -0.1); NNT = 112. There was numerically but not statistically significantly less aspiration in the NIV group as well. Longer-term outcomes like ventilator-free days, ICU length of stay and overall mortality were slightly lower in the NIV group but not statistically significantly.

Don’t strap NIV on a patient with hypopnea/apnea, severe altered mental status/ encephalopathy/ agitation, high risk of aspiration, active vomiting, hematemesis, severe epistaxis, or hemoptysis – as some examples.

How will this change my practice?
I’ve used NIV as a delayed sequence intubation technique but not for routine preoxygenation. NIV requires equipment, time, expertise, and expense, which makes it more cumbersome and could increase healthcare costs. However, this was a pragmatic trial and appears feasible. When we consider the association of peri-intubation hypoxemia with arrest and death and the actual reduction in risk of arrest in 1 out of every 112 intubations in PREOXI, it seems worth the time, hassle, and expense to me. I will be implementing NIV for preoxygenation in appropriate patients in my routine practice.

Editor’s note: A full 70% of eligible patients were excluded, meaning this applies only to a minority of patients. Also, more information on the cardiac arrest patients would be appreciated. If they were not hypoxic arrests then there’s likely something else about the protocol that’s beneficial, likely NIV slowing you down. ~ Nick Zelt

Noninvasive Ventilation for Preoxygenation During Emergency Intubation. N Engl J Med. 2024 Jun 13.