Intubation using apnoeic oxygenation to prevent desaturation: A systematic review and meta-analysis

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Oxygenation during the apnoeic phase preceding intubation in adults in prehospital, emergency department, intensive care and operating theatre environments

BACKGROUND

Apnoeic oxygenation is the delivery of oxygen during the apnoeic phase preceding intubation. It is used to prevent respiratory complications of endotracheal intubation that have the potential to lead to significant adverse events including dysrhythmia, haemodynamic decompensation, hypoxic brain injury and death. Oxygen delivered by nasal cannulae during the apnoeic phase of intubation (apnoeic oxygenation) may serve as a non-invasive adjunct to endotracheal intubation to decrease the incidence of hypoxaemia, morbidity and mortality.

OBJECTIVES

To evaluate the benefits and harms of apnoeic oxygenation before intubation in adults in the prehospital, emergency department, intensive care unit and operating theatre environments compared to no apnoeic oxygenation during intubation.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 4 November 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs that compared the use of any form of apnoeic oxygenation including high flow and low flow nasal cannulae versus no apnoeic oxygenation during intubation. We defined quasi-randomization as participant allocation to each arm by means that were not truly random, such as alternation, case record number or date of birth. We excluded comparative prospective cohort and comparative retrospective cohort studies, physiological modelling studies and case reports.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. hospital stay and 2. incidence of severe hypoxaemia. Our secondary outcomes were 3. incidence of hypoxaemia, 4. lowest recorded saturation of pulse oximetry (SpO2), 5. intensive care unit (ICU) stay, 6. first pass success rate, 7. adverse events and 8.

MORTALITY

We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included 23 RCTs (2264 participants) in our analyses. Eight studies (729 participants) investigated the use of low-flow (15 L/minute or less), and 15 studies (1535 participants) investigated the use of high-flow (greater than 15 L/minute) oxygen. Settings were varied and included the emergency department (2 studies, 327 participants), ICU (7 studies, 913 participants) and operating theatre (14 studies, 1024 participants). We considered two studies to be at low risk of bias across all domains. None of the studies reported on hospital length of stay. In predominately critically ill people, there may be little to no difference in the incidence of severe hypoxaemia (SpO2 less than 80%) when using apnoeic oxygenation at any flow rate from the start of apnoea until successful intubation (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.66 to 1.11; P = 0.25, I² = 0%; 15 studies, 1802 participants; low-certainty evidence). There was insufficient evidence of any effect on the incidence of hypoxaemia (SpO2 less than 93%) (RR 0.58, 95% CI 0.23 to 1.46; P = 0.25, I² = 36%; 3 studies, 489 participants; low-certainty evidence). There may be an improvement in the lowest recorded oxygen saturation, with a mean increase of 1.9% (95% CI 0.75% to 3.05%; P < 0.001, I² = 86%; 15 studies, 1525 participants; low-certainty evidence). There may be a reduction in the duration of ICU stay with the use of apnoeic oxygenation during intubation (mean difference (MD) ‒1.13 days, 95% CI ‒1.51 to ‒0.74; P < 0.0001, I² = 46%; 5 studies, 815 participants; low-certainty evidence). There may be little to no difference in first pass success rate (RR 1.00, 95% CI 0.93 to 1.08; P = 0.79, I² = 0%; 8 studies, 826 participants; moderate-certainty evidence). There may be little to no difference in incidence of adverse events including oral trauma, arrhythmia, aspiration, hypotension, pneumonia and cardiac arrest when apnoeic oxygenation is used. There was insufficient evidence about any effect on mortality (RR 0.84, 95% CI 0.70 to 1.00; P = 0.06, I² = 0%; 6 studies, 1015 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There was some evidence that oxygenation during the apnoeic phase of intubation may improve the lowest recorded oxygen saturation. However, the differences in oxygen saturation were unlikely to be clinically significant. This did not translate into any measurable effect on the incidence of hypoxaemia or severe hypoxaemia in a group of predominately critically ill people. We were unable to assess the influence on hospital length of stay; however, there was a reduction in ICU stay in the apnoeic oxygenation group. The mechanism for this is unclear as there was little to no difference in first pass success or adverse event rates.

Apneic oxygenation with low-flow oxygen cannula for rapid sequence induction and intubation in pediatric patients: a randomized-controlled trial

BACKGROUND

Classical rapid sequence induction and intubation (RSII) is used to reduce pulmonary aspiration, but it increases the risk of hypoxemia. Apneic oxygenation (ApOx) has been studied to prolong safe apneic time, and to decrease the incidence of hypoxemia in adults. The aim of this study was to investigate the effectiveness of ApOx via low-flow nasal cannula to reduce the incidence of hypoxemia in pediatric rapid sequence induction.

METHODS

This prospective single-blind randomized controlled trial included patients aged 0-7 years, American Society of Anesthesiologists (ASA) physical status 1 to 3, who underwent elective or emergency surgery under general anesthesia with rapid sequence induction during February 2020 to March 2021. Participants were randomized to the ApOx group or the classical rapid sequence induction group. The ApOx group received oxygen flow via regular nasal cannula, as follows: 1 liter per minute (LPM) in age 0-1 month, 2 LPM in age 1-12 months, and 4 LPM in age 1-7 years. The classical group did not receive oxygen supplementation during intubation. The primary outcome was the incidence of hypoxemia, defined as oxygen saturation (SpO₂) ≤92%.

RESULTS

Sixty-four participants were recruited. The incidence of hypoxemia in both groups was 8 of 32 participants (25%) (P=1.000). Among desaturated patients, the median time to desaturation was 29.5 and 35 seconds in the ApOx and classical groups, respectively (P=0.527). The median lowest SpO₂ was 91% and 88.5% in the ApOx and classical groups, respectively (P=0.079). In non-desaturated patients, the median time to successful intubation was 40.5 and 35.5 seconds in the ApOx and classical groups, respectively (P=0.069).

CONCLUSIONS

In this small sample study, ApOx using age-adjusted low-flow nasal cannula was ineffective for reducing the incidence of hypoxemia in pediatric RSII.

TRIAL REGISTRATION

Thai Clinical Trials Registry TCTR20210802002.

Incidence and factors associated with out-of-hospital peri-intubation cardiac arrest: a secondary analysis of the CURASMUR trial

The Incidence of peri-intubation cardiac arrest (PICA) has been rarely assessed in the out-of-hospital setting. The objectives of this study were to assess the incidence and factors associated with PICA (cardiac arrest occurring within 15 min of intubation) in an out-of-hospital emergency setting, wherein emergency physicians perform standardized airway management using a rapid sequence intubation technique in adult patients. This was a secondary analysis of the "Succinylcholine versus Rocuronium for out-of-hospital emergency intubation" (CURASMUR) trial, which compared the first attempt intubation success rate between succinylcholine and rocuronium in adult patients requiring emergency tracheal intubation for any vital distress except cardiac arrest. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. All operators were emergency physicians. The PICA incidence was recorded and multivariable logistic regression analysis was used to identify the factors associated with its occurrence. A total of 1226 patients were included with a mean age of 55.9 ± 19 years. PICA was recorded in 35 (2.8%) patients. Multivariable analysis indicated that the occurrence of PICA was independently associated with a body mass index (BMI) > 30 kg m² [adjusted odds ratio (aOR) 4.85; 95% confidence interval (CI) 1.82-12.90, p = 0.02], oxygen saturation (SpO₂) before intubation < 90% (aOR 3.4; 95% CI 1.50-7.60, p = 0.003), difficult intubation (defined by an Intubation Difficulty Score [IDS] > 5, [aOR 3.59; 95% CI 1.82-8.08, p = 0.02], the use of rocuronium instead of succinylcholine (aOR 2.47; 95% CI 1.08-5.64, p = 0.03), post intubation hypoxaemia (aOR 2.70; 95% CI 1.05-6.95, p = 0.04), post-intubation hypotension (aOR 4.07; 95% CI 1.62-10.22, p = 0.003), and pulmonary aspiration(aOR 4.78; 95% CI 1.48-15.36, p = 0.009). Early PICA occurred in approximately 3% of cases in the out-of-hospital setting. We identified several independent risk factors for PICA, including obesity, hypoxaemia before intubation and difficult intubation.

Apnoeic oxygenation during paediatric intubation: A systematic review

OBJECTIVE

This review assesses the effect of apnoeic oxygenation during paediatric intubation on rates of hypoxaemia, successful intubation on the first attempt and other adverse events.

DATA SOURCES

The databases searched included PubMed, Medline, CINAHL, EMBASE and The Cochrane Library. An electronic search for unpublished studies was also performed.

STUDY SELECTION

We screened studies that include children undergoing intubation, studies that evaluate the use of apnoeic oxygenation by any method or device with outcomes of hypoxaemia, intubation outcome and adverse events were eligible for inclusion.

DATA EXTRACTION

Screening, risk of bias, quality of evidence and data extraction was performed by two independent reviewers, with conflicts resolved by a third reviewer where consensus could not be reached.

DATA SYNTHESIS

From 362 screened studies, fourteen studies (N = 2442) met the eligibility criteria. Randomised controlled trials (N = 482) and studies performed in the operating theatre (N = 835) favoured the use of apnoeic oxygenation with a reduced incidence of hypoxaemia (RR: 0.34, 95% CI: 0.24 to 0.47, p < 0.001, I ² = 0% and RR: 0.27, 95% CI: 0.11 to 0.68, p = 0.005, I ² = 68% respectively). Studies in the ED and PICU were of lower methodological quality, displaying heterogeneity in their results and were unsuitable for meta-analysis. Among the studies reporting first attempt intubation success, there were inconsistent effects reported and data were not suitable for meta-analysis.

CONCLUSION

There is a growing body of evidence to support the use of apnoeic oxygenation during the intubation of children. Further research is required to determine optimal flow rates and delivery technique. The use of humidified high-flow oxygen shows promise as an effective technique based on data in the operating theatre, however its efficacy has not been shown to be superior to low flow oxygen in either the elective anesthetic or emergency intubation situations Systematic Review Registration: This review was prospectively registered in the PROSPERO international register of systematic reviews (Reference: CRD42020170884, registered April 28, 2020).

Apnoeic oxygenation for emergency anaesthesia of pre-hospital trauma patients

BACKGROUND

Efficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting. Adverse events occur more commonly in emergency airway management, and hypoxia is relatively frequent. The aim of this study was to establish whether passive apnoeic oxygenation was effective in reducing the incidence of desaturation during pre-hospital emergency anaesthesia.

METHODS

A prospective before-after study was performed to compare patients receiving standard care and those receiving additional oxygen via nasal prongs. The primary endpoint was median oxygen saturation in the peri-rapid sequence induction period, (2 minutes pre-intubation to 2 minutes post-intubation) for all patients. Secondary endpoints included the incidence of hypoxia in predetermined subgroups.

RESULTS

Of 725 patients included; 188 patients received standard treatment and 537 received the intervention. The overall incidence of hypoxia (first recorded SpO₂ < 90%) was 16.7%; 10.9% had SpO₂ < 85%. 98/725 patients (13.5%) were hypoxic post-intubation (final SpO₂ < 90% 10 minutes post-intubation). Median SpO₂ was 100% vs. 99% for the standard vs. intervention group. There was a statistically significant benefit from apnoeic oxygenation in reducing the frequency of peri-intubation hypoxia (SpO₂ < =90%) for patients with initial SpO₂ > 95%, p = 0.0001. The other significant benefit was observed in the recovery phase for patients with severe hypoxia prior to intubation.

CONCLUSION

Apnoeic oxygenation did not influence peri-intubation oxygen saturations, but it did reduce the frequency and duration of hypoxia in the post-intubation period. Given that apnoeic oxygenation is a simple low-cost intervention with a low complication rate, and that hypoxia can be detrimental to outcome, application of nasal cannulas during the drug-induced phase of emergency intubation may benefit a subset of patients undergoing emergency anaesthesia.

Comparison of Supraglottic Airway Devices With Endotracheal Intubation in Low-Risk Patients for Cesarean Delivery: Systematic Review and Meta-analysis

BACKGROUND

The safety and adverse event rate of supraglottic airway (SGA) devices for cesarean delivery (CD) is poorly characterized. The primary aims of this review were to determine whether the first-pass success was higher and time to insertion for SGA was faster than endotracheal intubation for elective CD. The secondary aim was to determine the airway-related adverse event rate associated with SGA use compared to endotracheal intubation in elective CD under general anesthesia (GA).

METHODS

Six databases were systematically searched until September 2019. Included studies reported on the use of SGA in comparison to endotracheal tube intubation. A comparative meta-analysis between SGA and endotracheal intubation was performed using RevMan 5.3 software. Dichotomous outcomes were reported using an odds ratio (OR) with 95% confidence interval (CI). The results for continuous outcomes were reported using a weighted mean difference (WMD) with 95% CI.

RESULTS

Fourteen studies with 2236 patients compared SGA and endotracheal intubation. Overall, there was no statistically significant difference in first-attempt success rate (OR = 1.92; 95% CI, 0.85-4.32; I = 0%; P = .44). There was no clinically significant difference in time to insertion (WMD = -15.80 seconds; 95% CI, -25.30 to -6.31 seconds; I= 100%; P = .001). Similarly, there was no difference in any adverse event rate except sore throat which was reduced with the use of an SGA (OR = 0.16; 95% CI, 0.08-0.32; I= 53%; P < .001).

CONCLUSIONS

Despite the reasonable insertion success rate and safety profile of SGAs demonstrated in this meta-analysis, the analysis remains underpowered and therefore inconclusive. At present, further studies are required before the use of an SGA as the first-line airway for an elective CD can be recommended.

Intubation practices for children in emergency departments and intensive care units across Australia and New Zealand: A survey of medical staff

OBJECTIVE

Intubation of children in the emergency setting is a high-risk, low incidence event. Standardisation of clinical practice has been hampered by a lack of high-quality evidence to support one technique over another. The aim of the present study is to determine clinician preference in intubation practice of children in EDs and ICUs in Australia and New Zealand to provide baseline information to allow future targeted research focused on improving the safety and efficacy of paediatric emergency airway management.

METHODS

The present study was a voluntary questionnaire undertaken by medical staff at registrar level or above in EDs and ICUs associated with the Paediatric Research in Emergency Departments International Collaborative (PREDICT) and Australia and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG) research networks. Respondents reported on their individual intubation practices, with a focus on pre-oxygenation and apnoeic oxygenation techniques, and the use of video laryngoscopy.

RESULTS

A total of 502 clinicians were invited to complete the survey between May and October 2018 with 336 (66.9%) responded. There was marked variation in practice between ED clinicians and ICU clinicians in the techniques used for pre-oxygenation, the frequency of use of apnoeic oxygenation and the reported use of video laryngoscopy.

CONCLUSIONS

Within Australia and New Zealand there is considerable variation in paediatric emergency airway clinical practice, in particular with respect to pre-oxygenation, apnoeic oxygenation and use of video laryngoscopy. Definitive clinical trials are required to best inform clinical practice in this area.

Pediatric airway: What is new in approaches and treatments?

Perioperative morbidity and mortality are high among patients in the extremes of life undergoing anesthesia. Complications in children occur mainly as a result of airway management-related events such as difficult approach, laryngospasm, bronchospasm and severe hypoxemia, which may result in cardiac arrest, neurological deficit or death. Reports and new considerations that have changed clinical practice in pediatric airway management have emerged in recent years. This narrative literature review seeks to summarize and detail the findings on the primary cause of morbidity and mortality in pediatric anesthesia and to highlight those things that anesthetists need to be aware of, according to the scientific reports that have been changing practice in pediatric anesthesia. This review focuses on the identification of “new” and specific practices that have emerged over the past 10 years and have helped reduce complications associated with pediatric airway management. At least 9 practices grouped into 4 groups are described: assessment, approach techniques, devices, and algorithms. The same devices used in adults are essentially all available for the management of the pediatric airway, and anesthesia-related morbidity and mortality can be reduced through improved quality of care in pediatrics.

Apneic Oxygenation for Pediatric Endotracheal Intubation: A Narrative Review

Apneic oxygenation (ApOx) has shown to be effective in adult populations in a variety of settings, including prehospital, emergency departments, intensive care units, and elective surgery. This review aims to assess the available literature for ApOx in the pediatric population to determine its effects on hypoxemia, safe apnea times, and flow rates employed safely.

[Statement of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) on the use of laryngeal tubes by ambulancemen and paramedics]

Due to an increasing number of severe complications reported during the prehospital application of laryngeal tubes, the Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) is prompted to formulate a respective statement. With regard to the current training situation and the applicable laws, ÖGARI recommends to convert the "Emergency Competence for Endotracheal Intubation (NKI)" for emergency paramedics into an "Emergency Competence for Extraglottic Airway Management, (NK-EGA)". Training should include at least 40 h of theoretical instruction, hands-on training on the manikin to secure mastery of the methodology and at least 20 successful applications under clinically elective conditions in adult patients under direct medical supervision. Here, depending on local conditions, both laryngeal mask and laryngeal tube can be used. In the prehospital environment, the device must be used which has been trained as mentioned above. Only 2nd generation EGA should be used. After successful EGA placement timely cuff pressure monitoring and gastric suction should be performed. The use of an EGA by ambulance-men cannot be recommended; these have to be limited to bag-mask ventilation.

Transnasal Humidified Rapid Insufflation Ventilatory Exchange in children requiring emergent intubation (Kids THRIVE): a protocol for a randomised controlled trial

INTRODUCTION

Emergency intubation of children with abnormal respiratory or cardiac physiology is a high-risk procedure and associated with a high incidence of adverse events including hypoxemia. Successful emergency intubation is dependent on inter-related patient and operator factors. Preoxygenation has been used to maximise oxygen reserves in the patient and to prolong the safe apnoeic time during the intubation phase. Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) prolongs the safe apnoeic window for a safe intubation during elective intubation. We designed a clinical trial to test the hypothesis that THRIVE reduces the frequency of adverse and hypoxemic events during emergency intubation in children and to test the hypothesis that this treatment is cost-effective compared with standard care.

METHODS AND ANALYSIS

The Kids THRIVE trial is a multicentre randomised controlled trial performed in participating emergency departments and paediatric intensive care units. 960 infants and children aged 0-16 years requiring emergency intubation for all reasons will be enrolled and allocated to THRIVE or control in a 1:1 allocation with stratification by site, age (<1, 1-7 and >7 years) and operator (junior and senior). Children allocated to THRIVE will receive weight appropriate transnasal flow rates with 100% oxygen, whereas children in the control arm will not receive any transnasal oxygen insufflation. The primary outcomes are defined as follows: (1) hypoxemic event during the intubation phase defined as SpO₂ <90% (patient-dependent variable) and (2) first intubation attempt success without hypoxemia (operator-dependent variable). Analyses will be conducted on an intention-to-treat basis.

ETHICS AND DISSEMINATION

Ethics approval for the protocol and consent process has been obtained (HREC/16/QRCH/81). The trial has been actively recruiting since May 2017. The study findings will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ACTRN12617000147381.

Does apneic oxygenation prevent desaturation during emergency airway management? A systematic review and meta-analysis

RéSUMé: OBJECTIF: L'oxygénation apnéique (OA) par lunettes nasales est une méthode de prévention de la désaturation en oxygène au cours des intubations en urgence. L'objectif de cette revue systématique était de déterminer l'efficacité de l'OA sur la prévention de la désaturation en oxygène au cours des intubations en urgence.

SOURCE

Des recherches systématiques ont été effectuées dans trois bases de données électroniques (MEDLINE, EMBASE et CINAHL) pour identifier les études portant sur la prévention de la désaturation en oxygène au moyen de l'OA par lunettes nasales. Notre critère d'évaluation principal était l'incidence des désaturations telle que définie dans chaque étude; nous avons ensuite évalué l'incidence de la désaturation sévère en oxygène (SpO₂ < 80%). Une méta-analyse a été effectuée sur les études présentant des données sur la désaturation en oxygène telle que définie par chaque étude et chez des patients ayant une désaturation sévère pour générer une estimation groupée de l'effet.

CONSTATATIONS PRINCIPALES

Au total, 544 études ont été examinées, parmi lesquelles dix (2 322 patients) satisfaisaient tous les critères d'éligibilité. Comparativement à l'absence d'OA, l'utilisation de cette méthode a été associée à une réduction de la désaturation en oxygène (risque relatif [RR] : 0,76; intervalle de confiance à 95% [IC] : 0,61 à 0,95; P = 0,02), mais n'a pas été associée à une réduction de la désaturation sévère (RR, 0,65; IC à 95% : 0,38 à 1,11; P = 0,12). Néanmoins, il y avait une hétérogénéité significative des facteurs liés aux patients, des interventions et des définitions de la désaturation en oxygène entre les études.

CONCLUSION

Nos constatations suggèrent que l'OA par lunettes nasales est associée à un moindre risque de désaturation en oxygène au cours des intubations en urgence. Cependant, compte de tenu de l'hétérogénéité des études, d'autres essais de grande qualité sont nécessaires pour déterminer quels patients pourraient bénéficier de l'OA au cours des intubations d'urgence.

Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials

BACKGROUND

We performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill.

METHODS

We searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation-based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration's Risk of Bias tool.

RESULTS

We identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study). Pre-oxygenation with non-invasive ventilation (NIV) and/or high-flow nasal cannula (HFNC) showed a possible beneficial role. Post-intubation recruitment improved oxygenation, while ramped position increased the number of intubation attempts and thiopental had negative hemodynamic effects. No effect was found for use of a checklist, apneic oxygenation (on oxygenation and hemodynamics), videolaryngoscopy (on number and length of intubation attempts), sedatives and neuromuscular blockers (on hemodynamics). Finally, videolaryngoscopy was associated with severe adverse effects in multiple trials.

CONCLUSIONS

The limited available evidence supports a beneficial role of pre-oxygenation with NIV and HFNC before intubation of critically ill patients. Recruitment maneuvers may increase post-intubation oxygenation. Ramped position increased the number of intubation attempts; thiopental had negative hemodynamic effects and videolaryngoscopy might favor adverse events.