Written by Clark Strunk
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This meta-analysis found that non-invasive positive pressure ventilation (NIPPV) during preoxygenation of critically ill patients undergoing tracheal intubation led to less hypoxemia compared to a facemask or high-flow nasal cannula (HFNC).
NIPPV is the way for me
Intubation is a relatively common––yet relatively high-risk––procedure in the emergency department and ICU. Adverse events such as hypoxemia and cardiovascular instability are frequent and have been associated with worse patient outcomes. One of the most effective interventions at curtailing hypoxemia is preoxygenation; however, guidelines and clinical practice vary regarding what strategy is most effective. This systematic review and meta-analysis of 15 RCTs and 3,420 patients demonstrated a lower risk of hypoxemia with NIPPV compared to facemask 0.51 (0.39-0.65) and with NIPPV compared to HFNC 0.73 (0.55-0.98). NIPPV was also not associated with increased risk of aspiration. HFNC had a lower risk of hypoxemia than facemask. There was no difference in mortality when comparing any of the different strategies for preoxygenation and no difference in first pass success. Rates of adverse events were lower with NIPPV compared to HFNC and facemask.
How does this change my practice?
NIPPV has become my standard method of preoxygenation for most critically ill patients, based initially on the PREOXI trial, and further underscored by this meta-analysis. Although there are likely some patients for whom a NIPPV first strategy for preoxygenation might not be strictly necessary, I think our ability to accurately predict which patients would and would not benefit from NIPPV is likely not as good as we may think. Furthermore, to address logistical barriers, using the same ventilator that the patient will go on for invasive mechanical ventilation for their NIPPV preoxygenation may also help facilitate more widespread uptake by respiratory therapists and clinicians at the bedside.
Source
Preoxygenation strategies for intubation of patients who are critically ill: a systematic review and network meta-analysis of randomised trials. Lancet Respir Med. 2025 Jul;13(7):585-596. doi: 10.1016/S2213-2600(25)00029-3. Epub 2025 Mar 21. PMID: 40127663
Hi. I did not notice if there was commentary about excluded patients. If there was any altered mentation (or maybe there was a GCS cutoff, or other mental status measure) were these patients generally excluded from NIPPV for pre-oxygenation prior to RSI? Or were some of them included. (Obviously, not ideal for the obtunded…)
This was a pragmatic trial. They mentioned not using it in people with active bleeding and to use clinical judgment as you would any patient you are starting on BiPAP. But it did push the boundaries with altered mental status. Even with that, aspiration risk was not higher in the NIPPV group. In fact, it was numerically (not statistically significantly) lower. Personally, I would use it even in altered patients as long as they are not actively bleeding from nose, mouth, or having active hematemesis. This is SO DIFFERENT than starting a COPD patient on BiPAP and walking away for 30 minutes. This is 3-minutes of NIPPV with you watching them EVERY SECOND. So, it appears safe even in patients with AMS.