Authors: Mickaël Vourc’h Pierre Asfar Christelle Volteau Konstantinos Bachoumas Noëmie Clavieras PierreYves Egreteau Karim Asehnoune Alain Mercat Jean Reignier Samir Jaber Gwenaël Prat Antoine Roquilly Noëlle Brule Daniel Villers Cédric Bretonniere Christophe Guitton
Publish Date: 2015/04/14
Volume: 41, Issue: 9, Pages: 1538-1548
Abstract
Intubation of hypoxemic patients is associated with lifethreatening adverse events Highflow therapy by nasal cannula HFNC for preoxygenation before intubation has never been assessed by randomized study Our objective was to evaluate the efficiency of HFNC for preoxygenation compared to high fractioninspired oxygen facial mask HFFMMulticenter randomized openlabelled controlled PREOXYFLOW trial NCT 01747109 in six French intensive care units Acute hypoxemic adults requiring intubation were randomly allocated to HFNC or HFFM Patients were eligible if PaO2/FiO2 ratio was below 300 mmHg respiratory rate at least 30/min and if they required FiO2 50 or more to obtain at least 90 oxygen saturation HFNC was maintained throughout the procedure whereas HFFM was removed at the end of general anaesthesia induction Primary outcome was the lowest saturation throughout intubation procedure Secondary outcomes included adverse events related to intubation duration of mechanical ventilation and deathA total of 124 patients were randomized In the intenttotreat analysis including 119 patients HFNC n = 62 HFFM n = 57 the median interquartile range lowest saturation was 915 80–96 for HFNC and 895 81–95 for the HFFM group p = 044 There was no difference for difficult intubation p = 018 intubation difficulty scale ventilationfree days p = 009 intubationrelated adverse events including desaturation 80 or mortality p = 046Takehome message Intubation in hypoxemic patients is a highrisk event Preoxygenation contributes to the safety of the procedure Strategies to decrease deep desaturation during intubation in hypoxemic patients have been little studied Despite theoretical advantages and widespread use randomized studies have never evaluated highflow therapy in preoxygenation before intubation for hypoxemic patients This study shows that this new device maintained in place from the beginning of preoxygenation to the end of the intubation procedure does not prevent deep desaturation during intubation in severely hypoxemic patientsContributors We thank Yohann FOUCHER EA4275 Biostatistician at Nantes University Hospital for assistance in designing the study We are grateful to all medical staff nurses and research staff at the six sites for inclusion and data collection We thank Monique MARGUERITE for administrative and logistic support and Marion RIGOT for creating the electronic case report form and Dr Anne Chiffoleau MD for safety monitoring Financial and material support for the research and grant funding and provision of equipment and supplies This study was supported by the French Ministry of Health Interregional French Clinical Hospital Research Program grant PHRCi 2012– API12/N/077 in addition to a grant for research innovation missions allocated to the university hospital of Nantes by Fisher Paykel Healthcare Nantes University Hospital sponsored the study Fisher Paykel participated for 14 of the total budget including supply of consumables to the six participating centres Fisher Paykel did not participate in the study design or in data collection analysis and interpretation of the data or in the writing review approval and decision to submit the manuscript for publicationDr Christophe Guitton and Dr Mickael Vourc’h had full access to all of the data in the study and take complete responsibility for the integrity of the data and the accuracy of the data analysis No conflict of interest Mickaël Vourc’h Christelle Volteau Konstantinos Bachoumas Noëmie Clavieras PierreYves Egreteau Jean Reignier Gwenaël Prat Noëlle Brule Daniel Villers Cedric Bretonniere Christophe Guitton Pr Asfar received consulting fees from LFB Pr Jaber received consulting fees from Dräger Hamilton Maquet and Fisher Paykel Pr Mercat received grant support clinical research from Covidien Maquet and General Electric and personal fees from Faron Pharmaceuticals member of steering committee Air Liquide Medical Systems and Covidien Pr Asehnoune served as board member for Astellas received grant support from Astellas and Pfizer lectured for BBraun and Fresenius Dr Roquilly reports conflict of interest with Merck laboratory investigator in a study
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