Background
Methods
Data sources and searches
Study selection and data extraction
Outcome measures
Risk of bias assessment
Statistical analysis and quality of evidence
Results
Literature search
Study characteristics
Study and published year | Settings | Participants | First intervention | Second intervention | PaO2 (mmHg) or PaO2/FiO2 ratio of the participants (mean ± SD or median [IQR]) | Key outcomes |
---|---|---|---|---|---|---|
Baillard et al. [6] 2006 | Two medical-surgical ICUs of 2 university hospitals in France | N = 53 Inclusion criteria: Acute respiratory failure requiring intubation Hypoxemia (PaO2 < 100 mmHg with 10 L/min O2 mask Exclusion criteria: encephalopathy or coma, cardiac resuscitation, hyperkalemia (> 5.5 mEq/L) | 3-min preoxygenation with a nonrebreather bag-valve mask driven by 15 L/min O2 Patient allowed to breathe spontaneously with occasional assistance | 3-min preoxygenation with NIV (PSV delivered by an ICU ventilator through a face mask adjusted to obtain an expired tidal volume of 7–10 ml/kg, FiO2 100%, PEEP 5 cmH2O) | PaO2: COT, 68 [60–79] NIV, 60 [57–89] | Drop in SpO2 during endotracheal intubation Regurgitation, new infiltrate on post-procedural chest X-ray, SpO2 < 80% during intubation, ICU mortality |
Vourc’h et al. [3] 2015 | Six French ICUs (3 medical, 2 medical-surgical, one surgical) | N = 119 Inclusion criteria: Adults (≥ 18 years) with acute hypoxemic respiratory failure (RR > 30 bpm and FiO2 ≥ 50% to obtain > 90% oxygen saturation, and estimated PaO2/FiO2 < 300 mmHg) requiring endotracheal intubation in ICU after RSI Exclusion criteria: cardiac arrest, asphyxia, intubation without RSI, Cormack-Lehane grade 4 glottis | 4-min preoxygenation with high FiO2 facial mask (15 L/min O2 flow) | 4-min preoxygenation with HFNC set to 60 L/min, of humidified oxygen flow (FiO2 100%); maintained in place throughout the endotracheal intubation | PaO2/ FiO2: Facial mask, 115.7 ± 63 HFNC, 120.2 ± 55.7 | Lowest SpO2 during endotracheal intubation Incidence of desaturation SpO2 < 80%, cardiovascular collapse (SBP < 80 or vasopressor introduction or increasing doses more than 30%), aspiration, 28-day mortality |
Jaber et al. [20] 2016 | Single-center medical and surgical ICU in France | N = 49 Inclusion criteria: Patients with severe hypoxemic acute respiratory failure (RR > 30 bpm, FiO2 requirement ≥ 50% to obtain > 90% SpO2 or an impossibility to obtain > 90% SpO2, estimated PaO2/FIO2 < 300 mmHg) admitted to ICU requiring mechanical ventilation Exclusion criteria: cardiocirculatory arrest | 4-min 30° head-up inclination with HFNC (humidified O2 flow 60 L/min, FiO2 100%) combined with NIV (PS 10 cmH2O, PEEP 5 cmH2O, FiO2 100%) | 4-min 30° head-up inclination with NIV (PS 10 cmH2O, PEEP 5 cmH2O, FiO2 100%) | PaO2/ FiO2: HFNC + NIV, 107 [74–264] NIV, 140 [83–201] | Minimal SpO2 during intubation, severe hypoxemia SpO2 < 80%, cardiovascular collapse (SBP < 65 mmHg at least once or < 90 mmHg lasting 30 min despite 500–1000 ml crystalloid loading or requiring introduction or increasing doses by more than 30% of vasoactive support), cardiac arrest, 28-day mortality |
Simon et al. [4] 2016 | Single center in Germany | N = 40 Inclusion criteria: Respiratory failure with hypoxemia (PaO2/FiO2 < 300 mmHg), indicated for endotracheal intubation, age ≥ 18 years Exclusion criteria Difficult airway, nasopharyngeal obstruction or blockage | 3-min preoxygenation using a BVM (adult size AMBU SPUR II disposable resuscitator with oxygen bag reservoir and without PEEP valve or pressure manometer), O2 10 L/min. No manual insufflation performed during apneic period. | 3-min preoxygenation using HFNC, oxygen flow 50 L/min, FiO2 1.0; left in place during the intubation procedure | PaO2/ FiO2: BVM, 205 ± 59 HFNC, 200 ± 57 | Lowest SpO2 during intubation, adverse events (cardiac arrest, arrhythmia, hemodynamic instability, aspiration of gastric contents) |
Baillard et al. [7] 2018 | Six sites in France | N = 201 Inclusion criteria: Adults patients (age > 18) with acute respiratory failure requiring intubation Exclusion criteria: Encephalopathy or coma, cardiac resuscitation, decompensation of chronic respiratory failure | 3-min preoxygenation with non-rebreathing BVM with an oxygen reservoir driven by 15 L/min O2; patient allowed to breathe spontaneously with occasional assists | 3-min preoxygenation using NIV—pressure support mode delivered by an ICU ventilator through a face mask adjusted to obtain an expired tidal volume of 6–8 ml/kg, FiO2 1.0, PEEP 5 cmH2O | PaO2/FiO2: BVM, 126 [95–207] HFNC, 132 [80–175] | Maximal value SOFA score within 7 days after intubation, requirement for an early stop of preoxygenation and immediate intubation, arrhythmia with hemodynamic failure, regurgitation, severe O2 desaturation SpO2 < 80%, 28-day mortality |
Guitton et al. [5] 2019 | Seven French ICU (4 medical, 2 medical-surgical, 1 surgical) | N = 184 Inclusion criteria: Adults patients (age > 18) requiring intubation in the ICU, without severe hypoxemia (PaO2/FiO2 < 200 mmHg) Exclusion criteria: Intubation without RSI (cardiac arrest), fiberoptic intubation, asphyxia, nasopharyngeal blockade, grade 4 glottis on Cormack-Lehane scale | 4-min preoxygenation in a head-up position with BVM (disposable self-inflating resuscitator with a reservoir bag, O2 set at 15 L/min) | 4-min preoxygenation in a head-up position with HFNC (60 L/min flow of headed and humidified oxygen FiO2 1.0, large or medium nasal cannulae chosen according to patients’ nostril size) | PaO2/ FiO2: BVM, 375 [276, 446] HFNC, 318 [242, 396] | Lowest SpO2 during intubation, SpO2 < 80%, aspiration, cardiac arrest, severe hypotension (SBP < 80 mmHg or vasopressor initiation or dose increment), 28-day mortality |
Frat et al. [8] 2019 | Twenty-eight ICUs in France | N = 313 Inclusion criteria: Patients (age > 18) admitted to the ICU requiring intubation, had acute hypoxemic respiratory failure (RR > 25 bpm or signs of respiratory distress, PaO2/FiO2 < 300 mmHg regardless of oxygenation strategy) Exclusion criteria: Cardiac arrest, altered consciousness (GCS < 8) | 3–5-min preoxygenation at 30° with HFNC with oxygen flow 60 L/min through a heated humidifier, FiO2 1.0. Clinicians performed a jaw thrust to maintain a patent upper airway, and continued high-flow oxygen therapy during laryngoscopy until endotracheal tube was placed into the trachea | 3–5-min preoxygenation at 30° with NIV—pressure support ventilation delivered via a face mask connected to an ICU ventilator, adjusted to obtain an expired tidal volume 6–8 ml/kg of predicted body weight with PEEP 5 cmH2O and FiO2 1.0 | PaO2/FiO2: HFNC, 148 ± 70 NIV, 142 ± 65 | Occurrence of an episode of severe hypoxemia (SpO2 < 80% for at least 5 s), lowest SpO2 during intubation, arterial hypotension, sustained arrhythmia, cardiac arrest, regurgitation, new infiltrate on chest radiography, 28-day mortality |
Risk of bias
Quality of evidence
Comparison | No. of trials | Direct estimate (95% CI) | Quality | Indirect estimate (95% CI) | Qualitye | NMA estimate (95% CI) | Quality |
---|---|---|---|---|---|---|---|
Lowest SpO2 during intubation (MD) | |||||||
HFNC vs. COT | 3 | − 1.64 (− 4.53, 1.25) | High | − 2.95 (− 8.23, 2.32) | Lowf,g | − 1.94 (− 4.48, 0.59) | High |
NIV vs. COT a | 2 | − 5.95 (− 9.38, − 2.53) | Moderateb | − 4.64 (− 9.58, 0.31) | Moderatef | − 5.53 (− 8.34, − 2.71) | Moderate |
HFNC vs. NIV | 1 | 3.00 (− 1.01, 7.01) | Lowb,c | 4.31 (− 0.17, 8.80) | Moderatef | 3.58 (0.59, 6.57) | Moderate |
HFNC and NIV vs. NIV | 1 | − 3.10 (− 11.18, 4.98) | Moderateb | Not estimablek | – | − 3.10 (− 11.18, 4.98) | Moderate |
SpO2 < 80% during intubation (OR) | |||||||
HFNC vs. COT | 3 | 0.79 (0.32, 1.94) | Moderatec | 0.44 (0.10, 1.95) | Very lowf,h | 0.67 (0.31, 1.46) | Moderate |
NIV vs. COT | 2 | 0.35 (0.13, 0.96) | Moderateb | 0.63 (0.15, 2.60) | Moderatef | 0.43 (0.19, 0.97) | Moderate |
HFNC vs. NIV | 1 | 1.25 (0.42, 3.75) | Moderatec | 2.23 (0.58, 8.60) | Lowf,g | 1.58 (0.67, 3.69) | Moderate |
HFNC and NIV vs. NIV | 1 | 0.16 (0.01, 1.80) | Moderatec | Not estimablek | 0.16 (0.01, 1.80) | Moderate | |
Intubation-related complicationsi (OR) | |||||||
HFNC vs. COT | 3 | 0.50 (0.27, 0.92) | High | 0.44 (0.08, 2.53) | Lowj | 0.49 (0.28, 0.88) | High |
NIV vs. COT | 2 | 0.38 (0.07, 2.06) | Very lowb,d | 0.44 (0.20, 0.96) | Moderateg | 0.43 (0.21, 0.87) | Moderate |
HFNC vs. NIV | 1 | 1.15 (0.70, 1.87) | Moderatec | 1.30 (0.22, 7.77) | Very lowj,g | 1.16 (0.72, 1.86) | Moderate |
HFNC and NIV vs. NIV | 1 | 1.20 (0.31, 4.61) | Lowd | Not estimablek | 1.20 (0.31, 4.61) | Low | |
Mortality (OR) | |||||||
HFNC vs. COT | 2 | 0.90 (0.55, 1.46) | High | 0.58 (0.29, 1.17) | Lowf,g | 0.78 (0.52, 1.16) | High |
NIV vs. COT | 2 | 0.68 (0.40, 1.14) | Moderateb | 1.04 (0.53, 2.04) | Lowf,g | 0.79 (0.53, 1.20) | Moderate |
HFNC vs. NIV | 1 | 0.86 (0.54, 1.37) | Moderateb | 1.32 (0.65, 2.70) | Lowf,g | 0.98 (0.66, 1.45) | Moderate |
HFNC and NIV vs. NIV | 1 | 0.78 (0.24, 2.55) | Lowd | Not estimablek | – | 0.78 (0.24, 2.55) | Low |
Clinical outcomes
Lowest SpO2 during intubation
HFNC and NIV | NIV | HFNC | COT | |
---|---|---|---|---|
Lowest SpO2 during intubation | 0.895 | 0.739 | 0.336 | 0.030 |
SpO2 < 80% during intubation | 0.957 | 0.634 | 0.344 | 0.066 |
Intubation-related complications | 0.560 | 0.774 | 0.595 | 0.071 |
Mortality | 0.689 | 0.556 | 0.598 | 0.157 |