Name: Preoxygenation Techniques for Tracheal Intubation in Critically Ill Adults Utilizing Oxygen Mask and Noninvasive Ventilation (Video) | JoVE Journal
Uploaded: 2025-12-05T13:35:00.000+00:00
Duration: 7 min 15 s
Description: Learn preoxygenation techniques for tracheal intubation in critically ill adults using oxygen masks and noninvasive ventilation. This method reduces hypoxemia risk and extends safe apnea time during emergent airway management.

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We would like to acknowledge Riya Mathew for providing administrative assistance.

The procedures described in this protocol were implemented in previously published studies, each of which received approval from the relevant Institutional Review Board (IRB) /Ethics Committee (EC). In those source studies, informed consent was obtained from participants or their legally authorized representatives, or a waiver of consent was granted by the approving IRB/EC, in accordance with applicable regulations and the Declaration of Helsinki. This article involves no new data collection by the authors and was not considered human subjects research by our institutional IRB. No identifiable individual data, images, or recordings are included in this article; therefore, consent for publication was not required. Individuals participating in the associated videos provided informed consent. The consumables and equipment used are listed in the Table of Materials.
1. Oxygen mask preoxygenation
NOTE: This procedure describes the use of an oxygen mask, either a non-rebreather or BVM, to achieve effective preoxygenation prior to induction and intubation.
<ol>
	<li>Position the patient supine in bed with the head of the bed elevated &#8805;30 degrees in a semi-fowler position as shown in Figure 1. 
	NOTE: If tolerated, a head-tilt, chin-lift position can further optimize airway patency.</li>
	<li>Ensure continuous cardiac monitoring and pulse oximetry (SpO2) devices are in place, and the blood pressure cuff is set to cycle at regular intervals (3-5 min) to monitor hemodynamic stability through the procedure. 
	NOTE: Whenever possible, ensure the SpO2 monitor and blood pressure cuff are on opposite extremities to prevent transient loss in SpO2 monitoring during cuff inflation.</li>
	<li>Prepare the oxygen delivery system by connecting a non-rebreather mask or BVM to a high flow oxygen source and allow the oxygen reservoir to fully inflate before applying the mask to the patient. 
	NOTE: If using a BVM, connect a PEEP-valve and set the PEEP to 8 cm H2O.</li>
	<li>Set the oxygen flow rate to at least 15 L/min. If using wall-mounted oxygen, turn the regulator to its highest setting (flush rate) to maximize delivered FiO2.</li>
	<li>Secure the mask on the patient&#39;s face and ensure there is a tight seal. 
	NOTE: Consider holding the mask with a two-handed &#34;C-E&#34; grip for optimal effectiveness, especially in patients with facial hair, obesity, or poor mask fit.</li>
	<li>Maintain preoxygenation for at least 3 min prior to induction of anesthesia to allow adequate denitrogenation and build up of oxygen reserves.</li>
	<li>During the preoxygenation phase, continuously monitor for preoxygenation failure, including hypoxia with declining SpO2, patient apnea, and patient desynchrony.</li>
	<li>After 3 min of preoxygenation, administer medications for the induction of anesthesia.</li>
	<li>Perform a jaw thrust immediately following induction of anesthesia to ensure airway patency, and maintain oxygen support throughout induction, and up to laryngoscopy.</li>
	<li>Continuously monitor the patient&#39;s oxygen saturation and adjust oxygen delivery as needed. 
	NOTE: If necessary, switch to manual bag mask ventilation to maintain oxygenation before endotracheal intubation.</li>
</ol>
2. NIV preoxygenation
NOTE: This procedure describes the use of bilevel positive airway pressure (BPAP) or a mechanical ventilator configured for NIV to perform preoxygenation prior to induction and intubation. The protocol for NIV-based preoxygenation is shown in Figure 2.
<ol>
	<li>Position the patient supine in bed with the head of the bed elevated &#8805;30 degrees in the semi-fowler position. 
	NOTE: If tolerated, a head-tilt, chin-lift position can further enhance upper airway patency.</li>
	<li>Apply standard monitoring, including continuous cardiac monitoring and pulse oximetry (SpO2) devices are in place, and the blood pressure cuff is set to cycle at regular intervals (3-5 min) to monitor hemodynamic stability through the procedure. 
	NOTE: Whenever possible, ensure the SpO2 monitor and blood pressure cuff are on opposite extremities to prevent transient loss in SpO2 monitoring during cuff inflation.</li>
	<li>Apply a tight-fitting NIV mask to prevent oxygen leakage and connect it to the bilevel positive airway pressure (BPAP) machine or mechanical ventilator configured for NIV use.</li>
	<li>Ensure the equipment is properly configured with a tight connection to the mask and the selected preoxygenation device, adequate oxygen supply, and that the circuit is free of leaks to optimize effective preoxygenation.</li>
	<li>Set the FiO2 to 100%. Adjust the expiratory pressure (EPAP/PEEP) to &#62;5 cm H2O. Set the inspiratory pressure (IPAP or equivalent pressure support) to &#62;10 cm H2O. Set the respiratory rate to &#8805;10 breaths/min to support ventilation.</li>
	<li>Preoxygenate the patient for at least 3 min prior to induction of anesthesia to allow for denitrogenation and increase oxygen reserves prior to apnea.</li>
	<li>During the preoxygenation phase, continuously monitor for markers of preoxygenation failure including hypoxia with declining SpO2, apnea, and patient desynchrony.</li>
	<li>After 3 min, administer medications for the induction of anesthesia.</li>
	<li>Perform a jaw thrust after induction of anesthesia to ensure airway patency, and maintain oxygen support throughout induction, and up to the initiation of laryngoscopy.</li>
	<li>Continuously monitor SpO2 and assess the patient&#39;s tolerance of NIV. 
	NOTE: If oxygenation does not improve, or patient distress occurs, adjust ventilator settings or switch to an alternative preoxygenation method such as manual bag-mask ventilation.</li>
</ol>

<ol><li>Pfuntner, A., Wier, L. M., Stocks, C. <a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=author%3aPfuntner%2C+A+%22Healthcare+Cost+and+Utilization+Project+%28HCUP%29+Statistical+Briefs%22">Healthcare Cost and Utilization Project (HCUP) Statistical Briefs</a>. , Agency for Healthcare Research and Quality (US). (2013).</li>
<li>Frerk, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Difficult+Airway+Society+2015+guidelines+for+management+of+unanticipated+difficult+intubation+in+adults%5BTitle%5D)+AND+%22Br+J+Anaesth%22%5BJournal%5D)">Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.</a> Br J Anaesth. 115 (6), 827-848 (2015).</li>
<li>Acquisto, N. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Society+of+critical+care+medicine+clinical+practice+guidelines+for+rapid+sequence+intubation+in+the+critically+Ill+adult+patient%5BTitle%5D)+AND+%22Crit+Care+Med%22%5BJournal%5D)">Society of critical care medicine clinical practice guidelines for rapid sequence intubation in the critically Ill adult patient.</a> Crit Care Med. 51 (10), 1411-1430 (2023).</li>
<li>Simpson, G. D., Ross, M. J., McKeown, D. W., Ray, D. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Tracheal+intubation+in+the+critically+ill%3A+A+multi-centre+national+study+of+practice+and+complications%5BTitle%5D)+AND+%22Br+J+Anaesth%22%5BJournal%5D)">Tracheal intubation in the critically ill: A multi-centre national study of practice and complications.</a> Br J Anaesth. 108 (5), 792-799 (2012).</li>
<li>Casey, J. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Bag-mask+ventilation+during+tracheal+intubation+of+critically+ill+adults%5BTitle%5D)+AND+%22N+Engl+J+Med%22%5BJournal%5D)">Bag-mask ventilation during tracheal intubation of critically ill adults.</a> N Engl J Med. 380 (9), 811-821 (2019).</li>
<li>Russotto, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intubation+practices+and+adverse+peri-intubation+events+in+critically+ill+patients+from+29+countries%5BTitle%5D)+AND+%22JAMA%22%5BJournal%5D)">Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries.</a> JAMA. 325 (12), 1164-1172 (2021).</li>
<li>Casey, J. D., Semler, M. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Ventilation+before+intubation%3A+How+to+prevent+hypoxaemia%5BTitle%5D)+AND+%22Lancet+Respir+Med%22%5BJournal%5D)">Ventilation before intubation: How to prevent hypoxaemia.</a> Lancet Respir Med. 7 (4), 284-285 (2019).</li>
<li>De Jong, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Cardiac+arrest+and+mortality+related+to+intubation+procedure+in+critically+ill+adult+patients%3A+a+multicenter+cohort+study%5BTitle%5D)+AND+%22Crit+Care+Med%22%5BJournal%5D)">Cardiac arrest and mortality related to intubation procedure in critically ill adult patients: a multicenter cohort study.</a> Crit Care Med. 46 (4), 532-539 (2018).</li>
<li>Gibbs, K. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Protocol+and+statistical+analysis+plan+for+the+pragmatic+trial+examining+oxygenation+prior+to+intubation+of+preoxygenation+with+noninvasive+ventilation+vs.+oxygen+mask+in+critically+ill+adults%5BTitle%5D)+AND+%22Chest+Crit+Care%22%5BJournal%5D)">Protocol and statistical analysis plan for the pragmatic trial examining oxygenation prior to intubation of preoxygenation with noninvasive ventilation vs. oxygen mask in critically ill adults.</a> Chest Crit Care. 1 (2), 100014(2023).</li>
<li>Gibbs, K. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Noninvasive+ventilation+for+preoxygenation+during+emergency+intubation%5BTitle%5D)+AND+%22N+Engl+J+Med%22%5BJournal%5D)">Noninvasive ventilation for preoxygenation during emergency intubation.</a> N Engl J Med. 390 (23), 2165-2177 (2024).</li>
<li>Roveri, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Preoxygenation+with+and+without+positive+end-expiratory+pressure+in+lung-healthy+volunteers%3A+A+randomized+clinical+trial%5BTitle%5D)+AND+%22JAMA+Netw+Open%22%5BJournal%5D)">Preoxygenation with and without positive end-expiratory pressure in lung-healthy volunteers: A randomized clinical trial.</a> JAMA Netw Open. 8 (5), e2511569(2025).</li>
<li>Baillard, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Noninvasive+ventilation+improves+preoxygenation+before+intubation+of+hypoxic+patients%5BTitle%5D)+AND+%22Am+J+Respir+Crit+Care+Med%22%5BJournal%5D)">Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients.</a> Am J Respir Crit Care Med. 174 (2), 171-177 (2006).</li>
<li>Baillard, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effect+of+preoxygenation+using+noninvasive+ventilation+before+intubation+on+subsequent+organ+failures+in+hypoxaemic+patients%3A+a+randomised+clinical+trial%5BTitle%5D)+AND+%22Br+J+Anaesth%22%5BJournal%5D)">Effect of preoxygenation using noninvasive ventilation before intubation on subsequent organ failures in hypoxaemic patients: a randomised clinical trial.</a> Br J Anaesth. 120 (2), 361-367 (2018).</li>
<li>Chiang, T. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Noninvasive+ventilation+for+preoxygenation+before+general+anesthesia%3A+a+systematic+review+and+meta-analysis+of+randomized+controlled+trials%5BTitle%5D)+AND+%22BMC+Anesthesiol%22%5BJournal%5D)">Noninvasive ventilation for preoxygenation before general anesthesia: a systematic review and meta-analysis of randomized controlled trials.</a> BMC Anesthesiol. 22 (1), 306(2022).</li>
<li>Frat, J. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Noninvasive+ventilation+versus+high-flow+nasal+cannula+oxygen+therapy+with+apnoeic+oxygenation+for+preoxygenation+before+intubation+of+patients+with+acute+hypoxaemic+respiratory+failure%3A+A+randomised%2C+multicentre%2C+open-label+trial%5BTitle%5D)+AND+%22Lancet+Respir+Med%22%5BJournal%5D)">Noninvasive ventilation versus high-flow nasal cannula oxygen therapy with apnoeic oxygenation for preoxygenation before intubation of patients with acute hypoxaemic respiratory failure: A randomised, multicentre, open-label trial.</a> Lancet Respir Med. 7 (4), 303-312 (2019).</li>
<li>Bailly, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Compared+efficacy+of+four+preoxygenation+methods+for+intubation+in+the+ICU%3A+retrospective+analysis+of+McGrath+Mac+videolaryngoscope+versus+Macintosh+laryngoscope+%28MACMAN%29+trial+data%5BTitle%5D)+AND+%22Crit+Care+Med%22%5BJournal%5D)">Compared efficacy of four preoxygenation methods for intubation in the ICU: retrospective analysis of McGrath Mac videolaryngoscope versus Macintosh laryngoscope (MACMAN) trial data.</a> Crit Care Med. 47 (4), e340-e348 (2019).</li>
<li>Fong, K. M., Au, S. Y., Ng, G. W. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Preoxygenation+before+intubation+in+adult+patients+with+acute+hypoxemic+respiratory+failure%3A+a+network+meta-analysis+of+randomized+trials%5BTitle%5D)+AND+%22Crit+Care%22%5BJournal%5D)">Preoxygenation before intubation in adult patients with acute hypoxemic respiratory failure: a network meta-analysis of randomized trials.</a> Crit Care. 23 (1), 319(2019).</li>
<li>Higgs, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Guidelines+for+the+management+of+tracheal+intubation+in+critically+ill+adults%5BTitle%5D)+AND+%22Br+J+Anaesth%22%5BJournal%5D)">Guidelines for the management of tracheal intubation in critically ill adults.</a> Br J Anaesth. 120 (2), 323-352 (2018).</li>
<li>Godwin, S. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+policy%3A+Critical+issues+in+the+management+of+adult+patients+requiring+endotracheal+intubation+in+the+emergency+department%5BTitle%5D)+AND+%22Ann+Emerg+Med%22%5BJournal%5D)">Clinical policy: Critical issues in the management of adult patients requiring endotracheal intubation in the emergency department.</a> Ann Emerg Med. 86 (2), e29-e68 (2025).</li>
</ol>

The authors declare no conflicts of interest.

Preoxygenation is a critical component of airway management in critically ill patients, aimed at reducing the risk for severe hypoxemia and its associated complications3,7,10,14. Both oxygen masks and NIV are commonly used techniques to achieve this goal, each with distinct advantages and limitations.
Oxygen masks, including non-rebreather masks and bag valve masks, are low-cost, widely available, simple, and rapidly deployed in emergency settings. When used with proper technique, including high-flow oxygen delivery and an adequate mask seal, these devices can deliver near 100% FiO2&#160;and provide effective preoxygenation. Using a (BVM) for preoxygenation additionally allows providers to provide manual ventilation during the apnea period after induction of anesthesia, and this can help maintain higher oxygen saturations while decreasing the risk for severe hypoxemia5. However, their effectiveness is limited by mask seal quality, oxygen flow, patient cooperation, and facial anatomy, which may be challenging in some critically ill patients. In contrast, NIV physiologic advantages for patients with select high-risk characteristics, such as hypotension (mean arterial pressure &#60;65 mmHg, or systolic blood pressure &#60;90 mmHg), hypoxemia prior to intubation, obesity, or age over 75 years8. NIV provides both oxygenation and ventilatory support, improves alveolar recruitment through PEEP, and has been shown to prolong safe apnea time and reduce the incidence of severe hypoxemia.
Multiple studies have demonstrated the efficacy of NIV in this context. In 2006, Baillard et al. showed that NIV resulted in higher oxygen saturations at the end of preoxygenation and observed that fewer patients preoxygenated with NIV experienced severe hypoxemia, defined as SpO2 less than 80%, when compared to standard oxygen masks12. A follow-up study by Baillard et al. in 2018 supported the continuation of NIV for patients already on BPAP finding that discontinuing NIV in the peri-intubation period resulted in a higher incidence of severe hypoxemia in patients already receiving it13. Patients with moderate to severe hypoxemia, defined as PaO2/FiO2&#60;200, warrant special attention. Frat and colleagues compared NIV to high flow nasal oxygen and found that severe hypoxemia (SpO2 &#60;80%) occurred in 24% of patients in the NIV group compared with 35% of patients in the high flow nasal oxygen group, with sensitivity analyses confirming that NIV preoxygenation reduced the risk of peri-intubation hypoxemia after adjusting for PaO2 at randomization15. A similar finding was observed by Bailly et al. in post hoc analysis of data examining preoxygenation, and they concluded that NIV may deserve preference in patients experiencing hypoxemia prior to intubation16. These findings are further supported by two meta-analyses that concluded that NIV was safe and likely the most effective pre-oxygenation method for preventing peri-intubation hypoxemia14,17. More recently, Gibbs et al compared pre-oxygenation with an oxygen mask and NIV, with results favoring NIV9,10. In this large trial of 1302 patients, they reported that an oxygen saturation &#60; 95% occurred less commonly in the NIV group as compared to the oxygen mask group (8.3% vs. 18.5%)9,10. In addition, NIV did not appear to increase the incidence of aspiration.
The increasing body of evidence supporting NIV as a safe, effective preoxygenation strategy is starting to be reflected in society&#39;s clinical guidelines as well. Guidelines now suggest preoxygenation with NIV for patients with severe hypoxemia3,18. A draft of clinical policy examining critical issues in managing endotracheal intubation in the emergency department, the American College of Emergency Physicians includes &#34;a level B recommendation for NIV stating that when feasible, providers should preoxygenate with NIV over conventional oxygen masks to avoid peri-intubation hypoxemia19.
Despite its benefits, NIV requires provider familiarity with ventilator settings and patient tolerance. Tight-fitting masks and high inspiratory pressures may cause discomfort, anxiety, or agitation. Strategies to improve tolerance include upright positioning, gradual pressure titration, and the judicious use of anxiolytics or sedatives such as dexmedetomidine or ketamine. Oxygen masks, while less physiologically robust, remain an important tool for preoxygenation, especially in settings where NIV is unavailable, contraindicated, or poorly tolerated. Clinicians must also address common technical challenges in both methods, such as air leaks due to poor mask seal. Techniques like the two-person mask hold, mask straps, or the use of anatomically contoured cushions can improve seal integrity and preoxygenation efficacy.
While current evidence supports the use of NIV as an effective and safe preoxygenation strategy in high-risk populations, several important knowledge gaps remain. Future research should focus on identifying which subgroups derive the greatest benefit from NIV, such as patients with underlying cardiopulmonary disease, sepsis, or altered mental status, and whether personalized preoxygenation strategies based on physiologic variables (e.g., lung ultrasound, oxygen reserve index) improve outcomes. Comparative effectiveness studies are also needed to evaluate NIV versus emerging technologies such as high-flow nasal oxygen with apneic oxygenation or dual-mode systems combining oxygenation and ventilation.
Additionally, implementation research is needed to address real-world barriers to adoption, including provider familiarity with equipment, time constraints in emergency settings, and variability in institutional protocols. In this context, video-based educational tools, such as those developed in this study, may serve as valuable resources to improve clinician training and promote consistent, evidence-based practice. Standardized video protocols can enhance knowledge translation, support just-in-time learning, and facilitate the dissemination of best practices across institutions with varying levels of expertise.
Finally, future work should also explore patient-centered outcomes such as comfort, anxiety, and mask tolerance during preoxygenation. These factors are critical in guiding sedation strategies and optimizing the safety and effectiveness of airway management in critically ill patients.
Conclusion
Effective preoxygenation is a cornerstone of safe tracheal intubation in critically ill patients, significantly reducing the risk of hypoxemia and its associated complications. A thorough understanding and proficiency in both NIV and oxygen mask techniques allow clinicians to individualize preoxygenation strategies based on patient-specific physiology and clinical context. Evidence increasingly supports the use of NIV, particularly in high-risk patients, as a superior method for optimizing oxygenation and prolonging the duration of safe apnea. Integrating these evidence-based practices into routine airway management can enhance patient safety and improve outcomes during emergency intubation. As critical care environments grow more complex, applying best practices in preoxygenation represents a practical and impactful intervention to reduce complications and support high-quality, reliable airway management.

Tracheal intubation is the third most common procedure performed in US hospitals, involving more than 1.6 million patients annually1. Successful tracheal intubation requires attention to multiple factors, including patient positioning, preoxygenation, apneic oxygenation, use of an induction agent, neuromuscular blockade, choosing a laryngoscope and endotracheal tube, laryngoscopy, endotracheal tube placement, confirmation of successful intubation, and initiation of mechanical ventilation2,3. In critically ill patients, tracheal intubation is a high-risk intervention. Despite advances in airway management, severe hypoxemia occurs during 10 to 20% of intubations performed in the emergency department (ED) and intensive care unit (ICU)4,5,6. The rapid onset of hypoxemia in this group of patients is primarily attributed to reduced functional residual capacity, impaired gas exchange, and high oxygen consumption7. Critically ill patients who develop hypoxemia during intubation are at increased risk of cardiac arrest and death6,8. Preoxygenation aims to replace alveolar nitrogen with oxygen to create an oxygen reservoir that prolongs the safe apnea period during laryngoscopy and intubation7. The absence of preoxygenation is associated with increased risk of peri-intubation cardiac arrest7,8.
Two primary preoxygenation techniques are widely used in clinical practice: oxygen masks and noninvasive ventilation (NIV)6,9,10. Oxygen masks, including non-rebreather masks and bag-valve masks (BVM), are simple and widely accessible tools capable of delivering up to 100% fraction of inspired oxygen (FiO2) at flow rates up to 15 L/min. However, their effectiveness is dependent on mask seal integrity and patient cooperation. In contrast, NIV enhances oxygenation by delivering oxygen under positive-end-expiratory pressure (PEEP) that helps to recruit atelectatic alveoli, improving gas exchange. Additionally, NIV can support ventilation in the apneic period through the addition of inspiratory positive airway pressure (IPAP) and the ability of the machine to provide a set respiratory rate. Patients requiring rapid intubation, who cannot tolerate setup delays or have limited apnea tolerance, are best served by oxygen mask-based preoxygenation, while those with severe hypoxemia, underlying parenchymal lung disease, or shunt physiology may derive greater benefit from preoxygenation with noninvasive ventilation due to its ability to improve alveolar recruitment and gas exchange.
Oxygen mask technique
Oxygen masks remain a mainstay for pre-oxygenation in critical care settings due to their simplicity and accessibility6,9. Preoxygenation using an oxygen mask can be performed with either a bag-mask or a non-rebreather mask6.
A bag-mask device consists of a self-filling bag connected to an oxygen source, an exhalation port to which a valve can be attached to add PEEP, and a tight-fitting face mask. Manual compression of the bag delivers oxygen-rich air to the patient, and passive oxygen delivery occurs during spontaneous breathing when the bag is not compressed. The addition of a PEEP valve during preoxygenation increases ventilation in the dependent lung regions, increases alveolar recruitment, and improves the fraction of expired oxygen, thereby potentially increasing the duration of safe apnea11.
A non-rebreather mask features a self-filling reservoir, a one-way inspiratory valve to prevent room air entrainment, and a loosely fitting face mask with two exhalation ports. This configuration allows for the delivery of high concentrations of inspired oxygen while minimizing dilution with ambient air.
Under optimal conditions, both devices are capable of delivering up to 100% FiO2, assuming a proper mask seal and adequate oxygen flow. However, their effectiveness may be compromised by patient agitation, poor mask fit, and the presence of airway obstruction.
Given their lower cost, ease of use, and rapid setup, oxygen masks are particularly useful in emergency situations and resource-limited settings. However, in patients with severe respiratory failure or those at high risk for desaturation, alternative preoxygenation methods, such as noninvasive ventilation, may provide superior oxygenation and extend the duration of safe apnea time.
Noninvasive Ventilation (NIV) technique
Preoxygenation can also be effectively achieved using NIV, which can deliver up to 100% FiO2 through a dedicated bilevel positive airway pressure (BPAP) machine, or a mechanical ventilator configured for noninvasive use. In addition to delivering high FiO2 through a tight-fitting mask, NIV can also provide assisted breaths at a set rate, enhancing ventilation and oxygenation.
A dedicated BPAP machine connects to the patient using a single limb design with an active exhalation port. BPAP machines use distinct nomenclature for the settings during inspiration and expiration. The IPAP represents the pressure delivered during inspiration to provide tidal volume and oxygenation. The expiratory positive airway pressure (EPAP) is the pressure delivered during expiration and is analogous to PEEP on a conventional ventilator that prevents alveolar collapse and improves gas exchange. NIV with BPAP pre-oxygenation is particularly beneficial for patients with severe hypoxemia, obesity, or underlying lung disease, as it improves alveolar recruitment and prolongs safe apnea time9,10,11.
In contrast, an invasive mechanical ventilator uses a dual-limb design with a closed circuit. Using an invasive mechanical ventilator for noninvasive ventilation requires a different type of mask from a dedicated BPAP machine. Specifically, when using a ventilator, the mask must be equipped to be compatible with the inhalation and exhalation limbs that connect to the ventilator. While some invasive ventilators feature a dedicated &#34;NIV&#34; mode with identical settings as the conventional BPAP machine, many ventilators can only perform modes of ventilation traditionally used for intubated patients. When a conventional ventilator does not have an &#34;NIV&#34; mode, a pressure mode of ventilation can be configured for preoxygenation. In this situation, PEEP is identical to EPAP. However, the inspiratory pressure (IP) on an invasive mechanical ventilator is the pressure provided in addition to PEEP during inspiration (IP = IPAP-BPAP). For example, to achieve a BPAP with IPAP 15 cm H2O and EPAP of 5 cm H20 using pressure control ventilation would require an inspiratory pressure of 10 cm H2O and a PEEP of 5 cm H2O (since inspiratory pressure is delivered in addition to PEEP).
Key factors influencing the efficacy of pre-oxygenation include FiO2, duration of pre-oxygenation, and preservation of a patient&#39;s functional residual capacity. While both face mask oxygenation and NIV are effective, NIV may offer added benefits in select populations, particularly those with respiratory distress, reduced oxygen reserves or impaired pulmonary mechanics10.
This article describes the techniques, clinical considerations, and supporting evidence for both preoxygenation methods, providing clinicians with essential knowledge to optimize airway management in critically ill patients.

<table><tbody><tr><td>Bag Mask with PEEP valve</td><td>Ambu A/S&amp;nbsp;</td><td>520 211 001</td><td>Bag Mask Ventilation for oxygen mask technique</td></tr><tr><td>BPAP</td><td>Philips</td><td>DSX700S11</td><td>BPAP for Noninvasive ventilation technique</td></tr><tr><td>Mechanical Ventilator</td><td>Hamilton</td><td>159001</td><td>Mechanical Ventilator&amp;nbsp; for Noninvasive ventilation technique</td></tr><tr><td>Non-Rebreather mask</td><td>Medline</td><td>HCS4600B</td><td>Non-Rebreather mask for oxygen mask technique</td></tr></tbody></table>

preoxygenation techniques for tracheal intubation in critically ill adults utilizing oxygen mask and noninvasive ventilation

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

Preoxygenation is a critical step in airway management aimed at reducing the risk of hypoxemia, a potentially life-threatening complication, during emergency tracheal intubation in critically ill patients. Challenges with ventilation and intubation are unpredictable, making it essential to optimize oxygenation prior to induction to improve patient safety. During the preoxygenation phase of intubation, a patient receives 100% fraction of inspired oxygen (FiO2) to replace alveolar nitrogen, increasing oxygen reserves, and arterial oxygen partial pressure (PaO2) to prolong safe apnea time. Preoxygenation strategies primarily rely on two categories of oxygen delivery systems: noninvasive ventilation (NIV) and oxygen masks. Each has unique advantages and limitations, and both have been studied in various clinical trials. When used effectively, these techniques optimize oxygenation, enhance first-pass intubation success, and reduce peri-intubation complications. This article reviews the physiological basis and technical application of oxygen masks and NIV-based preoxygenation strategies, discusses their comparative efficacy, and provides practical guidance on selecting and implementing the optimal approach based on patient condition and resource availability. By integrating best practices, clinicians can reduce complications and improve outcomes during emergency airway management in critically ill patients.

We present evidence-based preoxygenation strategies that demonstrate the use of oxygen masks and noninvasive positive pressure ventilation to optimize oxygenation in critically ill patients undergoing emergent tracheal intubation, thereby reducing the risk of hypoxemia, extending safe apnea time, and minimizing complications.

Preoxygenation is a critical step in airway management aimed at reducing the risk of hypoxemia, a potentially life-threatening complication, during ...

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.

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Research

JoVE Journal

Medicine

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Learn preoxygenation techniques for tracheal intubation in critically ill adults using oxygen masks and noninvasive ventilation. This method reduces hypoxemia risk and extends safe apnea time during emergent airway management.

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