Preoxygenation in critically ill patients requiring emergency tracheal intubation

Objective: To determine the effectiveness of preoxygenation with 100% oxygen in the critically ill patient in preparation for emergency tracheal intubation. Design: Nonrandomized, controlled trial. Setting: Large, level 1 trauma center, tertiary care intensive care unit. Patients: Critically ill patients failing noninvasive respiratory support techniques who require tracheal intubation followed by mechanical ventilation. Interventions: A baseline arterial blood gas was obtained on noninvasive therapy and 4 mins post-100% oxygen therapy with a bag-mask assembly. Best effort to achieve a tight-fitting mask seal was pursued coupled with other mask ventilation maneuvers to optimize noninvasive oxygenation and ventilation. Measurements and Main Results: A total of 42 patients consecutively intubated during the 15-month study period were studied. The baseline Pao(2) (mean +/- SD) with concurrent noninvasive support was 67 +/- 19.6 mm Hg (range, 43-88 mm Hg) and increased a mean of 37 mm Hg to 103.8 +/- 63.2 mm Hg after 4 mins of preoxygenation with 100% oxygen. A total of 36% of patients had minimal changes (+/-5%) in their baseline Pao(2), and only 19% increased their baseline Pao(2) by at least 50 mm Hg after preoxygenation maneuvers. Conclusions: The critically ill patient has little reserve to tolerate interruption of oxygen delivery and, thus, is at risk for hypoxemia during emergency airway management. Preoxygenation efforts as described in this clinical trial appear to be marginally effective in regard to providing a reasonable safeguard against hypoxemia during laryngoscopy and endotracheal intubation.