Should we follow the pre-oxygenation trial protocol?

From the Guidelines

We should follow the pre-oxygenation trial protocol, specifically using medication-assisted preoxygenation in patients undergoing Rapid Sequence Intubation (RSI) who are unable to tolerate a face mask, NIPPV, or HFNO due to agitation, delirium, or combative behavior. Preoxygenation is a critical step in preparing patients for intubation, as it helps create an oxygen reservoir in the lungs, providing a buffer against rapid desaturation during the apneic period of intubation 1. To implement preoxygenation:

• Use a non-rebreather mask or other suitable device to administer 100% oxygen for 3-5 minutes before attempting intubation
• Alternatively, consider using non-invasive positive pressure ventilation or high-flow nasal cannula for preoxygenation in patients with severe hypoxemia
• Monitor oxygen saturation to ensure adequate preoxygenation The goal of preoxygenation is to achieve an end-tidal oxygen concentration of at least 90%, which can help prevent hypoxemia and its potential complications, such as cardiac arrest or neurological injury during intubation attempts 1. Key considerations for preoxygenation include:
• Patient tolerance and ability to cooperate with the preoxygenation process
• Severity of hypoxemia and need for alternative preoxygenation methods
• Monitoring and adjustment of preoxygenation technique as needed to ensure adequate oxygenation.

From the Research

Pre-Oxygenation Trial Protocol

The decision to follow a pre-oxygenation trial protocol depends on various factors, including the specific context and the available evidence.

• The study 2 discusses the protocol and statistical analysis plan for the PREOXI trial, which compares preoxygenation with noninvasive ventilation versus oxygen mask among critically ill adults undergoing emergency tracheal intubation.
• The primary outcome of the PREOXI trial is the incidence of hypoxemia, defined as a peripheral oxygen saturation <85% between induction and 2 minutes after intubation.
• Another study 3 found that preoxygenation with noninvasive ventilation resulted in a lower incidence of hypoxemia during intubation than preoxygenation with an oxygen mask.

Considerations

When considering whether to follow a pre-oxygenation trial protocol, the following points should be taken into account:

• The effectiveness of noninvasive ventilation and oxygen mask preoxygenation for the prevention of hypoxemia during emergency tracheal intubation, as investigated in the PREOXI trial 2.
• The results of the study 3, which suggest that preoxygenation with noninvasive ventilation may be a more effective strategy for reducing hypoxemia during intubation.
• The potential risks and benefits of preoxygenation, including the risk of hypoxemia and the potential benefits of reducing this risk.

Related Studies

Other studies have investigated related topics, including:

• The introduction of provisional approvals for medicines 4, which highlights the importance of caution when introducing new treatments.
• The comparison of restrictive and liberal oxygen strategies in trauma patients 5, which found no significant difference in death and/or major respiratory complications between the two groups.
• The evaluation of progressive exercise compared with best-practice advice, with or without corticosteroid injection, for rotator cuff disorders 6, which found no evidence of a difference in shoulder pain and function between the progressive exercise intervention and the best-practice advice intervention.