High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: a randomized controlled clinical trial
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Intubation of hypoxemic patients is associated with life-threatening adverse events. High-flow therapy by nasal cannula (HFNC) for preoxygenation before intubation has never been assessed by randomized study. Our objective was to evaluate the efficiency of HFNC for preoxygenation, compared to high fraction-inspired oxygen facial mask (HFFM).
Multicenter, randomized, open-labelled, controlled PREOXYFLOW trial (NCT 01747109) in six French intensive care units. Acute hypoxemic adults requiring intubation were randomly allocated to HFNC or HFFM. Patients were eligible if PaO2/FiO2 ratio was below 300 mmHg, respiratory rate at least 30/min and if they required FiO2 50 % or more to obtain at least 90 % oxygen saturation. HFNC was maintained throughout the procedure, whereas HFFM was removed at the end of general anaesthesia induction. Primary outcome was the lowest saturation throughout intubation procedure. Secondary outcomes included adverse events related to intubation, duration of mechanical ventilation and death.
A total of 124 patients were randomized. In the intent-to-treat analysis, including 119 patients (HFNC n = 62; HFFM n = 57), the median (interquartile range) lowest saturation was 91.5 % (80–96) for HFNC and 89.5 % (81–95) for the HFFM group (p = 0.44). There was no difference for difficult intubation (p = 0.18), intubation difficulty scale, ventilation-free days (p = 0.09), intubation-related adverse events including desaturation <80 % or mortality (p = 0.46).
Compared to HFFM, HFNC as a preoxygenation device did not reduce the lowest level of desaturation.
KeywordsPreoxygenation High-flow oxygen therapy Severe hypoxemia Intubation
Contributors: We thank Yohann FOUCHER, EA4275 Biostatistician at Nantes University Hospital, for assistance in designing the study. We are grateful to all medical staff, nurses, and research staff at the six sites for inclusion and data collection. We thank Monique MARGUERITE for administrative and logistic support and Marion RIGOT for creating the electronic case report form; and Dr Anne Chiffoleau, MD for safety monitoring. Financial and material support for the research and grant, funding and provision of equipment and supplies: This study was supported by the French Ministry of Health (Interregional French Clinical Hospital Research Program grant (PHRCi 2012– API12/N/077) in addition to a grant for research & innovation missions allocated to the university hospital of Nantes by Fisher & Paykel Healthcare. Nantes University Hospital sponsored the study. Fisher & Paykel participated for 14 % of the total budget including supply of consumables to the six participating centres. Fisher & Paykel did not participate in the study design or in data collection, analysis and interpretation of the data, or in the writing, review, approval and decision to submit the manuscript for publication.
Conflicts of interest
Dr. Christophe Guitton and Dr. Mickael Vourc’h had full access to all of the data in the study and take complete responsibility for the integrity of the data and the accuracy of the data analysis. No conflict of interest: Mickaël Vourc’h, Christelle Volteau, Konstantinos Bachoumas, Noëmie Clavieras, Pierre-Yves Egreteau, Jean Reignier, Gwenaël Prat, Noëlle Brule, Daniel Villers, Cedric Bretonniere, Christophe Guitton. Pr Asfar received consulting fees from LFB. Pr Jaber received consulting fees from Dräger, Hamilton, Maquet and Fisher Paykel. Pr Mercat received grant support (clinical research) from Covidien, Maquet and General Electric and personal fees from Faron Pharmaceuticals (member of steering committee), Air Liquide Medical Systems and Covidien. Pr Asehnoune served as board member for Astellas, received grant support from Astellas and Pfizer; lectured for B-Braun and Fresenius. Dr Roquilly reports conflict of interest with Merck laboratory (investigator in a study).
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