Intensive Care Medicine

, Volume 43, Issue 2, pp 226–228 | Cite as

Understanding preoxygenation and apneic oxygenation during intubation in the critically ill

  • Jarrod M. MosierEmail author
  • Cameron D. Hypes
  • John C. Sakles
Understanding the Disease

The most common adverse event encountered during the intubation of critically ill patients is oxygen desaturation, which is often a harbinger of serious complications such as cardiovascular collapse, anoxic brain injury, and death. It is imperative to attenuate this risk by optimizing preoxygenation prior to intubation. This paper explores the physiology and challenges related to preoxygenation and maintenance of oxygenation during intubation in these high-risk patients.

The purpose of preoxygenation is to maintain hemoglobin saturation despite ongoing oxygen consumption during apnea. This is accomplished in principle by denitrogenating the alveoli so that the functional residual capacity (FRC) serves as an oxygen reservoir, the efficacy of which can be evaluated by the fraction of expired O 2 (FeO 2) (Fig.  1).


FeO2 Functional Residual Capacity Nasal Cannula Alveolar Recruitment Shunt Fraction 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Compliance with ethical standards

Conflicts of interest

None for all authors.


  1. 1.
    Groombridge C, Chin CW, Hanrahan B et al (2016) Assessment of common preoxygenation strategies outside of the operating room environment. Acad Emer Med 23(3):342–346CrossRefGoogle Scholar
  2. 2.
    Hayes-Bradley C, Lewis A, Burns B et al (2015) Efficacy of nasal cannula oxygen as a preoxygenation adjunct in emergency airway management. Ann Emer Med. doi: 10.1016/j.annemergmed.2015.11.012
  3. 3.
    Baraka AS, Taha SK, El-Khatib MF et al (2003) Oxygenation using tidal volume breathing after maximal exhalation. Anesth Analg 97(5):1533–1535CrossRefPubMedGoogle Scholar
  4. 4.
    Baraka AS, Taha SK, Aouad MT et al (1999) Preoxygenation: comparison of maximal breathing and tidal volume breathing techniques. Anesthesiology 91(3):612–616CrossRefPubMedGoogle Scholar
  5. 5.
    Papazian L, Corley A, Hess D et al (2016) Use of high-flow nasal cannula oxygenation in ICU adults: a narrative review. Intensive Care Med. doi: 10.1007/s00134-016-4277-8
  6. 6.
    Mort TC (2005) Preoxygenation in critically ill patients requiring emergency tracheal intubation. Crit Care Med 33(11):2672–2675CrossRefPubMedGoogle Scholar
  7. 7.
    Mort TC, Waberski BH, Clive J (2009) Extending the preoxygenation period from 4 to 8 mins in critically ill patients undergoing emergency intubation. Crit Care Med 37(1):68–71CrossRefPubMedGoogle Scholar
  8. 8.
    Baillard C, Fosse JP, Sebbane M et al (2006) Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med 174(2):171–177CrossRefPubMedGoogle Scholar
  9. 9.
    Sakles JC, Mosier J, Patanwala AE et al (2016) First pass success without hypoxemia is increased with the use of apneic oxygenation during RSI in the emergency department. Acad Emer Med 23(6):703–10Google Scholar
  10. 10.
    Miguel-Montanes R, Hajage D, Messika J et al (2015) Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia. Crit Care Med 43(3):574–583CrossRefPubMedGoogle Scholar
  11. 11.
    Vourc’h M, Asfar P, Volteau C et al (2015) High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: a randomized controlled clinical trial. Intensive Care Med 41(9):1538–1548CrossRefPubMedGoogle Scholar
  12. 12.
    Semler MW, Janz DR, Lentz RJ et al (2016) Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. Am J Respir Crit Care Med 193(3):273–280CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Engstrom J, Hedenstierna G, Larsson A (2010) Pharyngeal oxygen administration increases the time to serious desaturation at intubation in acute lung injury: an experimental study. Crit Care 14(3):R93CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Besnier E, Guernon K, Bubenheim M et al (2016) Pre-oxygenation with high-flow nasal cannula oxygen therapy and non-invasive ventilation for intubation in the intensive care unit. Intensive Care Med. doi: 10.1007/s00134-016-4369-5
  15. 15.
    Hanouz JL, Lammens S, Tasle M et al (2015) Preoxygenation by spontaneous breathing or noninvasive positive pressure ventilation with and without positive end-expiratory pressure: a randomised controlled trial. Eur J Anaesthesiol 32(12):881–887PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2016

Authors and Affiliations

  • Jarrod M. Mosier
    • 1
    • 2
    Email author
  • Cameron D. Hypes
    • 1
    • 2
  • John C. Sakles
    • 2
  1. 1.Section of Pulmonary, Critical Care, Allergy and Sleep, Department of MedicineUniversity of ArizonaTucsonUSA
  2. 2.Department of Emergency MedicineUniversity of ArizonaTucsonUSA

Personalised recommendations