Association of Two Preoxygenation Approaches With Hypoxemia During Tracheal Intubation: A Secondary Analysis

Christopher D Chou; Jessica A Palakshappa; HarLeigh Haynie; Katelyn Garcia; Dustin Long; Kevin W Gibbs; Pragmatic Critical Care Research Group

doi:10.1016/j.annemergmed.2025.06.003

Association of Two Preoxygenation Approaches With Hypoxemia During Tracheal Intubation: A Secondary Analysis

Ann Emerg Med. 2025 Nov;86(5):511-517. doi: 10.1016/j.annemergmed.2025.06.003. Epub 2025 Jul 22.

Authors

Christopher D Chou¹, Jessica A Palakshappa¹, HarLeigh Haynie¹, Katelyn Garcia¹, Dustin Long¹, Kevin W Gibbs²; Pragmatic Critical Care Research Group¹

Collaborators

Affiliations

¹ Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest School of Medicine, Winston-Salem, NC; Department of Biostatistics (Haynie, Garcia, Long), Wake Forest School of Medicine, Winston-Salem, NC.
² Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest School of Medicine, Winston-Salem, NC; Department of Biostatistics (Haynie, Garcia, Long), Wake Forest School of Medicine, Winston-Salem, NC. Electronic address: kevin.gibbs@advocatehealth.org.

PMID: 40699168
DOI: 10.1016/j.annemergmed.2025.06.003

Abstract

Study objectives: Oxygen masks (bag-valve-mask device and nonrebreathing facemask oxygen) are the most common method of preoxygenation in critically ill patients undergoing emergency tracheal intubation in the emergency department and intensive care unit. Whether the type of oxygen mask used for preoxygenation alters the risk of hypoxemia during intubation is uncertain. We sought to compare the incidence of hypoxemia during intubation in patients preoxygenated with a bag-valve-mask device to the incidence of hypoxemia in patients preoxygenated with facemask oxygen.

Methods: We conducted a secondary analysis of 2 randomized trials of emergency tracheal intubation. The primary outcome of hypoxemia was defined as a peripheral oxygen saturation <85% between induction of anesthesia and 2 minutes after tracheal intubation. We used a propensity-weighted multivariable logistic regression model to compare the incidence of hypoxemia between groups. We hypothesized that preoxygenation with a bag-valve-mask device would be associated with a lower incidence of hypoxemia compared to preoxygenation with facemask oxygen.

Results: We included 1,156 patients in this analysis, of whom 136 were preoxygenated with a bag-valve-mask device and 1,020 were preoxygenated with facemask oxygen. Hypoxemia occurred in 20 of 136 (14.7%) participants in the bag-valve-mask device group and 153 of 1,020 (15.0%) participants in the facemask oxygen group. In the multivariable analysis, participants preoxygenated with a bag-valve-mask device had similar odds of hypoxemia to those preoxygenated with facemask oxygen (adjusted odds ratio 1.22, 95% confidence interval 0.72 to 2.16).

Conclusion: In critically ill patients undergoing tracheal intubation, preoxygenation with a bag-valve-mask device did not reduce the risk of hypoxemia compared to preoxygenation with facemask oxygen.

Keywords: Critical care; Oxygen; Oxygen mask; Preoxygenation; Tracheal intubation.

Publication types

Randomized Controlled Trial

MeSH terms

Aged
Critical Illness / therapy
Emergency Service, Hospital
Female
Humans
Hypoxia* / epidemiology
Hypoxia* / etiology
Hypoxia* / prevention & control
Incidence
Intubation, Intratracheal* / adverse effects
Intubation, Intratracheal* / methods
Male
Masks*
Middle Aged
Oxygen Inhalation Therapy* / instrumentation
Oxygen Inhalation Therapy* / methods
Oxygen Saturation
Oxygen* / administration & dosage
Secondary Data Analysis

Substances

Oxygen