Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults

Abstract

BACKGROUND Hypoxemia is the most common complication during tracheal intubation of critically ill adults and may increase the risk of cardiac arrest and death. Whether positive-pressure ventilation with a bag-mask device (bag-mask ventilation) during tracheal intubation of critically ill adults prevents hypoxemia without increasing the risk of aspiration remains controversial. METHODS In a multicenter, randomized trial conducted in seven intensive care units in the United States, we randomly assigned adults undergoing tracheal intubation to receive either ventilation with a bag-mask device or no ventilation between induction and laryngoscopy. The primary outcome was the lowest oxygen saturation observed during the interval between induction and 2 minutes after tracheal intubation. The secondary outcome was the incidence of severe hypoxemia, defined as an oxygen saturation of less than 80%. RESULTS Among the 401 patients enrolled, the median lowest oxygen saturation was 96% (interquartile range, 87 to 99) in the bag-mask ventilation group and 93% (interquartile range, 81 to 99) in the no-ventilation group (P = 0.01). A total of 21 patients (10.9%) in the bag-mask ventilation group had severe hypoxemia, as compared with 45 patients (22.8%) in the no-ventilation group (relative risk, 0.48; 95% confidence interval [CI], 0.30 to 0.77). Operator-reported aspiration occurred during 2.5% of intubations in the bag-mask ventilation group and during 4.0% in the no-ventilation group (P = 0.41). The incidence of new opacity on chest radiography in the 48 hours after tracheal intubation was 16.4% and 14.8%, respectively (P = 0.73). CONCLUSIONS Among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation. (Funded by Vanderbilt Institute for Clinical and Translational Research and others; PreVent ClinicalTrials.gov number, NCT03026322.)

Advancing emergency airway management practice and research

“…By contrast, in patients with inadequate spontaneous ventilation, preoxygenation should be undertaken using gentle positive pressure ventilation with BVM. In the intensive care unit (ICU) setting, patients receiving ventilation with BVM during the interval between induction and laryngoscopy had higher oxygen saturations and lower rates of severe hypoxemia than those receiving no ventilation …”

Noninvasive ventilation support during fiberoptic bronchoscopy-guided nasotracheal intubation effectively prevents severe hypoxemia

“…Although a brief period of apnea is safe after proper preoxygenation in most patients, individuals with preexisting pulmonary disorders may develop severe hypoxemia very rapidly, and maintaining ventilatory support and oxygen supply during intubation may thus be beneficial for patients at risk of severe hypoxemia. Casey et al showed that using BVM ventilation in critically ill patients between induction and laryngoscopy resulted in higher oxygen saturation and a lower incidence of severe hypoxemia compared with patients receiving no ventilation [14]. Miguel-Montanes et al reported that highflow nasal cannula (HFNC) oxygenation significantly improved preoxygenation and reduced the prevalence of severe hypoxemia during tracheal intubation compared with BVM [15].…”

High-flow nasal cannula therapy as apneic oxygenation during endotracheal intubation in critically ill patients in the intensive care unit: a systematic review and meta-analysis

“…Each year in the United States, approximately 1.5 million patients are estimated to receive endotracheal intubation and the rate of intubation is increasing in the hospital 1 . Hypoxemia, a frequently reported complication of intubation, is considered a predisposing factor for cardiac arrest and death [2][3][4][5] .…”