PREOXI
Noninvasive Ventilation for Preoxygenation during Emergency Intubation
On this page
Overview
Before emergency intubation, NIV preoxygenation reduced hypoxemia compared with an oxygen mask.
Clinical takeaway
PREOXI supports preoxygenating critically ill adults with noninvasive ventilation rather than an oxygen mask when the goal is to avoid peri-intubation hypoxemia.
Key result
Among 1301 enrolled, hypoxemia (oxygen saturation <85%) occurred in 9.1% (57 of 624) with NIV vs 18.5% (118 of 637) with an oxygen mask (difference -9.4 percentage points; 95% CI -13.2 to -5.6; p<0.001).
Practice impact
Prefer noninvasive ventilation for preoxygenation before emergency tracheal intubation.
Evidence
Study design
Multicenter randomized trial at 24 emergency departments and intensive care units in the United States.
Enrollment
1,301
Follow-up
From induction of anesthesia through 2 minutes after tracheal intubation.
Geography
United States
Clinical question
Does preoxygenation with noninvasive ventilation reduce hypoxemia during emergency tracheal intubation compared with an oxygen mask?
Population
- Critically ill adults (age 18 years or older) undergoing tracheal intubation.
Intervention
Preoxygenation with noninvasive ventilation.
Comparator
Preoxygenation with an oxygen mask.
Primary outcome
Hypoxemia during intubation, defined as oxygen saturation less than 85% from induction of anesthesia through 2 minutes after tracheal intubation.
Noninvasive ventilation for preoxygenation reduced peri-intubation hypoxemia compared with an oxygen mask.
Risk difference / -9.4 / 95% CI -13.2 to -5.6 / p<0.001
Key results
- Among 1301 enrolled, hypoxemia occurred in 57 of 624 (9.1%) with noninvasive ventilation vs 118 of 637 (18.5%) with an oxygen mask; difference -9.4 percentage points (95% CI -13.2 to -5.6; p<0.001).
- Cardiac arrest: 0.2% with noninvasive ventilation vs 1.1% with an oxygen mask (difference -0.9 percentage points; 95% CI -1.8 to -0.1).
- Aspiration: 0.9% vs 1.4% (difference -0.4 percentage points; 95% CI -1.6 to 0.7).
Harms
- Aspiration occurred in 0.9% of the noninvasive-ventilation group and 1.4% of the oxygen-mask group.
- Cardiac arrest was less common with noninvasive ventilation (0.2% vs 1.1%).
Clinical Use
Practice impact
- Prefer noninvasive ventilation for preoxygenation before emergency tracheal intubation.
Applicability
- Most applicable to critically ill adults undergoing emergency tracheal intubation in a U.S. emergency department or ICU.
Limitations
- The abstract does not specify noninvasive-ventilation settings or oxygen-mask type.
- The primary analysis included 624 noninvasive-ventilation and 637 oxygen-mask patients among 1301 enrolled.
- Cardiac arrest was less common with noninvasive ventilation, but it was not the primary outcome.
Common misinterpretations
- PREOXI tests preoxygenation strategy, not the entire intubation sequence or laryngoscope choice.
- Aspiration was not higher with noninvasive ventilation in this trial, so fear of aspiration alone is a weak reason to default to a mask.
Related evidence
Citation
Gibbs KW, Semler MW, Driver BE, et al. Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. 2024;390(23):2165-2177. doi:10.1056/NEJMoa2313680
Among critically ill adults undergoing tracheal intubation, preoxygenation with noninvasive ventilation resulted in a lower incidence of hypoxemia during intubation than preoxygenation with an oxygen mask.
- PMID
- 38869091