Preoxygenation strategies for endotracheal intubation in resource-limited settings: reframing the basics

Huynh, D.Q., Trieu, N.H.K. & Pham, T.T.N. Preoxygenation strategies for endotracheal intubation in resource-limited settings: reframing the basics. Crit Care 29, 259 (2025). https://doi.org/10.1186/s13054-025-05508-2

Summary

This editorial reviews evidence-based strategies for preoxygenation during endotracheal intubation (ETI) specifically tailored to resource-limited settings (LRS). The authors underscore the challenges faced in achieving optimal preoxygenation where advanced devices are unavailable. They propose practical, low-cost alternatives and highlight recent evidence supporting the effectiveness of methods such as high-flow nasal cannula (HFNC), non-invasive positive pressure ventilation (NIPPV), and bag-mask ventilation (BMV) with positive end-expiratory pressure (PEEP) valves. The goal is to maximize oxygenation, prolong safe apnea time, and reduce complications during ETI in critical care environments with limited resources.

Key Points:

1. Clinical Importance of Preoxygenation: Preoxygenation is essential for safely performing endotracheal intubation (ETI) in critically ill patients, particularly in those with acute hypoxemic respiratory failure (AHRF), by preventing rapid desaturation during the apneic period of intubation.
2. Limitations in Traditional Methods: Standard approaches such as simple face masks or conventional bag-mask ventilation (BMV) without PEEP are often insufficient for maintaining adequate oxygenation in critically ill patients, particularly those with compromised functional residual capacity (FRC).
3. Superior Methods – HFNC and NIPPV: Recent meta-analyses show high-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) significantly outperform traditional oxygenation methods. Specifically, NIPPV reduced hypoxemia incidence and severe adverse events compared with HFNC and standard masks.
4. Role of NIPPV: NIPPV is especially effective for preoxygenation in moderate-to-severe hypoxemia, significantly improving FRC and alveolar recruitment, and subsequently decreasing the risk of hypoxemia during ETI.
5. Combined Modalities Approach: Combining NIPPV and HFNC is effective in maintaining oxygen saturation during ETI, particularly beneficial in patients with severe respiratory impairment, obesity, or significant comorbidities.
6. Challenges in Resource-Limited Settings (LRS): Advanced methods such as HFNC and NIPPV may be unavailable in resource-limited environments, necessitating simpler, adaptable, and locally feasible solutions tailored to available equipment.
7. Low-Cost Alternatives: In settings where advanced techniques are unavailable, a practical solution includes combining a flush-rate oxygen mask (standard oxygen flowmeter opened fully) and nasal cannula at high flow rates, enhancing oxygen delivery and apneic oxygenation.
8. BMV with PEEP Valves: BMV incorporating a PEEP valve, widely accessible in emergency kits, has been demonstrated to significantly reduce severe hypoxemia incidence without increasing aspiration risk, making it a practical alternative for improving preoxygenation in LRS.
9. Mapleson C Circuit Utilization: The Mapleson C circuit, another low-cost option, enables clinicians to better assess patient respiratory mechanics (effort, rate, and compliance), improving control over tidal volumes compared to self-inflating bags, despite limitations in high-demand scenarios.
10. Future Directions: Research efforts should validate simplified, cost-effective methods like nasal cannula at flush rates, basic CPAP systems, BMV with PEEP valves, and Mapleson C circuits as viable alternatives to advanced techniques, along with developing standardized preoxygenation protocols and training modules for LRS.

Conclusion

Effective preoxygenation strategies in resource-limited settings rely heavily on adapting basic principles and leveraging available devices. Clinicians should individualize approaches by maximizing inspired oxygen concentration, ensuring adequate preoxygenation duration, and applying PEEP to optimize functional residual capacity. Simple yet effective measures like flush-rate oxygen delivery, patient positioning, and PEEP application via BMV represent critical tools to enhance patient safety during emergency ETI procedures in LRS.

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Watch the following video on "Preoxygenation & Apneic Oxygenation Strategies for Intubation" by PulmCritCare

Discussion Questions

1. How can clinicians effectively integrate training for alternative preoxygenation techniques into routine practice in resource-limited ICUs?
2. What potential barriers exist in implementing simple methods such as BMV with PEEP valves or the Mapleson C circuit widely, and how might these be overcome?
3. Given the promising evidence, should low-cost preoxygenation strategies become standard practice even in settings where advanced devices are partially available?

Javier Amador-Castañeda, BHS, RRT, FCCM, PNAP

Interprofessional Critical Care Network (ICCN)

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