Sage Advice: Using NIV for Pre-oxygenation prior to Intubation

Written by Sage Whitmore, MD

whitemore blog picReferenced below are three of the better articles on this subject, which provide fairly convincing evidence that in hypoxic patients (PNA, ARDS, etc.), a few minutes on NIV prior to intubation will get you a higher starting saturation, safer apnea time, and much less of a drastic desaturation during the attempt. I invite our providers and RTs to be familiar with this concept so that we have it as an option in the right patients if the airway doc is inclined to use it.

My practice is to wheel the vent to the bedside, set it to Spontaneous/Pressure Support 5 over 5, FiO2 of 100%, back-up rate of nothing (4 or 6, something very low so there is no asynchrony), hook the hose up to a NIV mask and place on the patient for a few minutes while I set up for the airway. Then after drugs are pushed, I hold the NIV mask over the mouth with a jaw thrust, let the patient take their last few breaths, and then hold the mask there for 45-60 seconds while the drugs kick in (NOT giving any breaths—still technically an RSI). This keeps the patient PEEPed open and maintains an O2 gradient flowing from circuit to alveoli. Then I pop the mask off, intubate, and hook the circuit up to the tube with an ETCO2 detector, and start them on lung-protective settings right away.

Delayed Sequence Intubation: A Prospective Observational Study. Weingart, Scott D. et al. Annals of Emergency Medicine , Volume 65 , Issue 4 , 349 – 355.

An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Jaber et al. Intensive Care Med. 2010 Feb;36(2):248-55.

Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Baillard et al. Am J Respir Crit Care Med. 2006 Jul 15;174(2):171-7. Epub 2006 Apr 20.