Preoxygenation Techniques for Tracheal Intubation in Critically Ill Adults Utilizing Oxygen Mask and Noninvasive Ventilation

In this video, we will explain the techniques of preoxygenation. We will not focus on equipment, medications, or other parts of the intubation process that are equally important. It's a critical procedure where outcomes can be improved by setting it right from the beginning.

We are planning to discuss preoxygenation using an oxygen mask, bag-valve mask, and compare it to non-invasive ventilation, where there is some data to show that it can potentially improve outcomes. The goal of preoxygenation is to dehydrogenate the patient, increase the safe apnea time, and reduce complications. We hope that you will learn how to do these techniques right and use both techniques depending upon your resources, as well as settings, and know when to use and how to use each of these techniques.

Since this is a demonstration video on a mannequin, we will not be using protective gear such as fluid shields, masks, but we expect that during the performance of this procedure you'd be wearing protective equipment, as is standard across the technique. To begin, position the patient's supine in the bed with the head of the bed elevated to at least 30 degrees in a semi-Fowler position. Apply continuous cardiac monitoring and place pulse oximetry sensors on the patient.

Ensure the blood pressure cuff is secured and set to cycle every three to five minutes to monitor hemodynamic stability. Connect a non-rebreather mask or bag-valve mask to a high-flow oxygen source to prepare the oxygen delivery system. Allow the oxygen reservoir to fully inflate before placing the mask on the patient.

Set the oxygen flow rate to at least 15 liters per minute. If using wall-mounted oxygen, turn the regulator to its maximum setting to achieve flush-rate oxygen delivery. Now secure the oxygen mask on the patient's face and ensure a tight seal.

Maintain preoxygenation for a minimum of three minutes to allow for adequate hydrogenation and oxygen reserve buildup. Continuously monitor for signs of preoxygenation failure, such as declining oxygen saturation, apnea, or patient desynchrony during the preoxygenation phase. Immediately after anesthesia induction, perform a jaw thrust to maintain airway patency.

Continue oxygen support until laryngoscopy begins. If oxygenation becomes inadequate, switch to manual bag ventilation by mask if the patient is not adequately ventilating. Position the patient's supine in bed with the head of the bed elevated to at least 30 degrees in the semi-Fowler position.

If tolerated, apply a head tilt and chin lift to enhance upper airway patency. Apply standard monitoring, including continuous cardiac monitoring and pulse oximetry devices. Secure the blood pressure cuff and set it to cycle every three to five minutes to track hemodynamic stability.

Position the pulse oximeter and cuff on opposite limbs when possible to avoid signal loss during cuff inflation. Apply a tight-fitting NIV mask on the patient to minimize oxygen leakage. Connect the mask to a bi-level positive airway pressure machine for NIV use.

Check the system to ensure a tight mask device connection and adequate oxygen supply, and that the ventilator circuit is leak free for effective preoxygenation. Now set the fraction of inspired oxygen to 100%Adjust the expiratory pressure and the inspiratory pressure. Set the respiratory rate to above 10 breaths per minute.

Preoxygenate the patient for at least three minutes to allow for dehydrogenation and to increase oxygen reserves before apnea. Continuously monitor for signs of preoxygenation failure, including declining oxygen saturation, apnea, and patient desynchrony. Perform a jaw thrust immediately following induction to ensure airway patency.

Continue oxygen support up until laryngoscopy begins. Monitor the patient's oxygen saturation and assess tolerance to non-invasive ventilation. If oxygenation becomes inadequate, switch to manual bag ventilation by mask if the patient is not adequately ventilating.

The incidence of oxygen desaturation during preoxygenation and intubation was lower with non-invasive ventilation compared to the oxygen mask, hypoxemia during intubation, and peri-intubation SpO2 less than 80%No significant difference in aspiration rates was observed between non-invasive ventilation and oxygen mask techniques. There was no difference in first attempt intubation success between the non-invasive ventilation and oxygen mask groups. This important procedure helps to prevent many complications that's associated with intubation.

First of all, it helps to wash out nitrogen in the lungs, which increases our oxygen status before we intubate. This allows you to have a first pass success rate because you are not rushing to get the tube in due to the risk of hypoxia during that procedure. It also extends that safe apnea time that you will have during the intubation process.

It gives you more time to secure the airway before oxygen levels become critically low. It allows us to have reduced complications such as cardiac and circulatory collapse due to hypoxemia. We will have less risk for arrhythmias, and it allows us to have respiratory arrest during the intubation.