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Compared Efficacy of Four Preoxygenation Methods for Intubation in the ICU

Retrospective Analysis of McGrath Mac Videolaryngoscope Versus Macintosh Laryngoscope (MACMAN) Trial Data

Bailly, Arthur, MD1; Ricard, Jean-Damien, MD, PhD2,3; Le Thuaut, Aurelie, MSc4,5; Helms, Julie, MD, PhD6,7; Kamel, Toufik, MD8; Mercier, Emmanuelle, MD9; Lemiale, Virginie, MD10; Colin, Gwenhael, MD1; Mira, Jean-Paul, MD, PhD11; Clere-Jehl, Raphaël, MD6,7; Messika, Jonathan, MD, PhD2,3; Dequin, Pierre-Francois, MD, PhD9; Boulain, Thierry, MD8; Azoulay, Elie, MD, PhD10; Champigneulle, Benoit, MD12; Reignier, Jean, MD, PhD13; Lascarrou, Jean-Baptiste, MD13 for the Clinical Research in Intensive Care and Sepsis Group (CRICS-TRIGGERSEP)

doi: 10.1097/CCM.0000000000003656
Online Clinical Investigations

Objectives: Severe hypoxemia is the most common serious adverse event during endotracheal intubation. Preoxygenation is performed routinely as a preventive measure. The relative efficacy of the various available preoxygenation devices is unclear. Here, our objective was to assess associations between preoxygenation devices and pulse oximetry values during endotracheal intubation.

Design: Post hoc analysis of data from a multicenter randomized controlled superiority trial (McGrath Mac Videolaryngoscope Versus Macintosh Laryngoscope [MACMAN]) comparing videolaryngoscopy to Macintosh laryngoscopy for endotracheal intubation in critical care.

Setting: Seven French ICUs.

Patients: Three-hundred nineteen of the 371 critically ill adults requiring endotracheal intubation who were included in the MACMAN trial.

Interventions: None.

Measurements and Main Results: Minimal pulse oximetry value during endotracheal intubation was the primary endpoint. We also sought risk factors for pulse oximetry below 90%. Of 319 patients, 157 (49%) had bag-valve-mask, 71 (22%) noninvasive ventilation, 71 (22%) non-rebreathing mask, and 20 (7%) high-flow nasal oxygen for preoxygenation. Factors independently associated with minimal pulse oximetry value were the Simplified Acute Physiology Score II severity score (p = 0.03), baseline pulse oximetry (p < 0.001), baseline PaO2/FIO2 ratio (p = 0.02), and number of laryngoscopies (p = 0.001). The only independent predictors of pulse oximetry less than 90% were baseline pulse oximetry (odds ratio, 0.71; 95% CI, 0.64–0.79; p < 0.001) and preoxygenation device: with bag-valve-mask as the reference, odds ratios were 1.10 (95% CI, 0.25–4.92) with non-rebreathing mask, 0.10 (95% CI, 0.01–0.80) with noninvasive ventilation, and 5.75 (95% CI, 1.15–28.75) with high-flow nasal oxygen.

Conclusions: Our data suggest that the main determinants of hypoxemia during endotracheal intubation may be related to critical illness severity and to preexisting hypoxemia. The differences across preoxygenation methods suggest that noninvasive ventilation may deserve preference in patients with marked hypoxemia before endotracheal intubation. Ongoing studies will provide further clarification about the optimal preoxygenation method for endotracheal intubation in critically ill patients.

1Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France.

2AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France.

3INSERM, IAME 1137, Université Paris Diderot, Paris, France.

4Clinical Research Unit, District Hospital Centre, La Roche-sur-Yon, France.

5Delegation a la Recherche Clinique et a l’Innovation- Hotel Dieu University Hospital, Nantes, France.

6Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France.

7EA 7293, Fédération de Médecine Translationnelle de Strasbourg (FMTS), School of Medicine, Strasbourg University, Strasbourg, France.

8Medical Intensive Care Unit, Regional Hospital Center, Orleans, France.

9Medical Intensive Care Unit, University Hospital, Tours, France.

10APHP, Saint Louis University Hospital, Medical ICU, Paris, France.

11Medical Intensive Care Unit, Cochin University Hospital, Paris, France.

12APHP, Surgical Intensive Care Unit, Georges Pompidou European University Hospital, Paris, France.

13Medical Intensive Care Unit, University Hospital, Nantes, France.

All members of the Clinical Research in Intensive Care and Sepsis Group (CRICS-TRIGGERSEP) can be found at

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The nonprofit healthcare institution “Centre Hospitalier Departement de la Vendee” was the study funder and sponsor.

Dr. Ricard received funding from Fisher & Paykel (travel expenses to attend scientific meetings). Dr. Le Thuaut disclosed work for hire. Dr. Messika received funding from Fisher & Paykel. Dr. Azoulay’s institution received funding from Alexion, Astellas, Baxter, Merck Sharp and Dohme, Ablynx, and Fisher & Paykel, and he received funding from lectures from Alexion, Astellas, Baxter, MSD, and Ablynx. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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