Comparison of Pre-Oxygenation Using High-Flow Nasal Oxygen vs Tight Face Mask During Rapid Sequence Induction
DOI:
https://doi.org/10.54112/bcsrj.v6i3.1644Keywords:
Pre-oxygenation, High Flow Nasal Oxygen (HFNO), Tight Face Mask, Airway ManagementAbstract
Pre-oxygenation prior to rapid sequence induction (RSI) is critical in minimizing the risk of hypoxemia during emergency surgeries. High-flow nasal oxygen (HFNO) has emerged as a promising alternative to conventional facemask pre-oxygenation; however, data from multicenter, real-time emergency settings remain limited. Objective: To compare the effectiveness of high-flow nasal oxygen versus tight-fitting facemask pre-oxygenation in preventing desaturation during RSI among adults undergoing emergency surgery. Methods: This randomized controlled trial was conducted at the Anesthesia Department of Gujranwala Teaching Hospital between September 2024 and February 2025. A total of 144 adult patients requiring emergency surgery and RSI were randomized equally into the HFNO group (n=77) and facemask group (n=77). All participants were pre-oxygenated with 100% oxygen. The primary outcome was the incidence of oxygen desaturation (SpO₂ <93%) from the start of pre-oxygenation to one minute after tracheal intubation. Secondary outcomes included rates of regurgitation and end-tidal carbon dioxide (EtCO₂) levels post-intubation. Statistical analysis was performed using the Chi-square test, and p ≤ 0.05 was considered significant. Results: Desaturation <93% occurred in 5 patients (2.9%) in the HFNO group and six patients (3.4%) in the facemask group (p = 0.77), indicating no significant difference. No increase in desaturation risk was noted during on-call hours. Regurgitation rates and EtCO₂ levels after intubation were comparable between groups. No adverse events related to either technique were reported. Conclusion: Both high-flow nasal oxygen and tight-fitting facemask pre-oxygenation are safe and effective in maintaining adequate oxygenation during RSI in emergency surgeries. HFNO offers comparable outcomes and may be considered a viable alternative, particularly in settings where facemask pre-oxygenation may be less practical.
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References
Baillard C, Boubaya M, Statescu E, et al. Incidence and risk
factors of hypoxaemia after preoxygenation at induction of
anaesthesia. British Journal of Anaesthesia 2019; 122: 388–94.
Nimmagadda U, Salem MR, Crystal GJ. Preoxygenation:
physiologic basis, benefits, and potential risks. Anesthesia and
Analgesia 2017; 124: 507–17.
Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic
oxygenation during prolonged laryngoscopy in obese patients:
a randomized, controlled trial of nasal oxygen administration.
Journal of Clinical Anesthesia 2010; 22: 164–8.
Taha SK, Siddik-Sayyid SM, El-Khatib MF, Dagher CM, Hakki
MA, Baraka AS. Nasopharyngeal oxygen insufflation following
pre-oxygenation using the four deep breath technique.
Anaesthesia 2006; 61: 427–30.
Teller LE, Alexander CM, Frumin MJ, Gross JB. Pharyngeal
insufflation of oxygen prevents arterial desaturation during
apnea. Anesthesiology 1988; 69: 980–2.
Gebremedhn EG, Mesele D, Aemero D, Alemu E. The incidence
of oxygen desaturation during rapid sequence induction and
intubation. World Journal of Emergency Medicine 2014; 5:
–85.
Cook TM, Scott S, Mihai R. Litigation related to airway and
respiratory complications of anaesthesia: an analysis of claims
against the NHS in England 1995–2007. Anaesthesia 2010; 65:
–63.
Cook TM, Woodall N, Frerk C, Fourth National Audit P. Major
complications of airway management in the UK: results of the
Fourth National Audit Project of the Royal College of
Anaesthetists and the Difficult Airway Society. Part 1:
anaesthesia. British Journal of Anaesthesia 2011; 106: 617–31.
Patel A, Nouraei SA. Transnasal Humidified Rapid-Insufflation
Ventilatory Exchange (THRIVE): a physiological method of
increasing apnoea time in patients with difficult airways.
Anaesthesia 2015; 70: 323–9.
Gustafsson IM, Lodenius A, Tunelli J, Ullman J, Jonsson FM.
Apnoeic oxygenation in adults under general anaesthesia
using Transnasal Humidified Rapid-Insufflation Ventilatory
Exchange (THRIVE) - a physiological study. British Journal of
Anaesthesia 2017; 118: 610–7.
Forsberg IM, Ullman J, Hoffman A, Eriksson LI, Lodenius A,
Fagerlund MJ. Lung volume changes in Apnoeic Oxygenation
using Transnasal Humidified Rapid-Insufflation Ventilatory
Exchange (THRIVE) compared to mechanical ventilation in
adults undergoing laryngeal surgery. Acta Anaesthesiologica
Scandinavica 2020; 64: 1491–8.
Lodenius A, Piehl J, Ostlund A, Ullman J, Jonsson Fagerlund M.
Transnasal humidified rapid-insufflation ventilatory exchange
(THRIVE) vs. facemask breathing pre-oxygenation for rapid
sequence induction in adults: a prospective randomised nonblinded clinical trial. Anaesthesia 2018; 73: 564–71.
Mir F, Patel A, Iqbal R, Cecconi M, Nouraei SA. A randomised
controlled trial comparing transnasal humidified rapid
insufflation ventilatory exchange (THRIVE) pre-oxygenation
with facemask pre-oxygenation in patients undergoing rapid
sequence induction of anaesthesia. Anaesthesia 2017; 72:
–43.
Egol KA, Tolisano AM, Spratt KF, Koval KJ. Mortality rates
following trauma: the difference is night and day. Journal of
Emergencies, Trauma and Shock 2011; 4: 178–83.
McHill AW, Wright KP Jr. Cognitive Impairments during the
transition to working at night and on subsequent night shifts.
Journal of Biological Rhythms 2019; 34: 432–46.
Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society
guidelines for management of unanticipated difficult
intubation in adults. British Journal of Anaesthesia 2015; 115:
–48.
Hermez LA, Spence CJ, Payton MJ, Nouraei SAR, Patel A,
Barnes TH. A physiological study to determine the mechanism
of carbon dioxide clearance during apnoea when using
transnasal humidified rapid insufflation ventilatory exchange
(THRIVE). Anaesthesia 2019; 74: 441–9.
Pillai A, Daga V, Lewis J, Mahmoud M, Mushambi M, Bogod D.
High-flow humidified nasal oxygenation vs. standard face mask
oxygenation. Anaesthesia 2016; 71: 1280–3.
Au K, Shippam W, Taylor J, Albert A, Chau A. Determining the
effective pre-oxygenation interval in obstetric patients using
high-flow nasal oxygen and standard flow rate facemask: a
biased-coin up-down sequential allocation trial. Anaesthesia
; 75: 609–16.
Hua Z, Liu Z, Li Y, Zhang H, Yang M, Zuo M. Transnasal
humidified rapid insufflation ventilatory exchange vs. facemask
oxygenation in elderly patients undergoing general
anaesthesia: a randomized controlled trial. Scientific Reports
; 10: 5745.
Parke RL, Bloch A, McGuinness SP. Effect of very-high-flow
nasal therapy on airway pressure and end-expiratory lung
impedance in healthy volunteers. Respiratory Care 2015; 60:
–403.
Riva T, Meyer J, Theiler L, et al. Measurement of airway pressure
during high-flow nasal therapy in apnoeic oxygenation: a
randomised controlled crossover trial*. Anaesthesia 2021; 76:
–35.
McLellan E, Lam K, Behringer E, et al. High-flow nasal oxygen
does not increase the volume of gastric secretions during
spontaneous ventilation. British Journal of Anaesthesia 2020;
: e75–80.
Seet MM, Soliman KM, Sbeih ZF. Comparison of three modes of
positive pressure mask ventilation during induction of
anaesthesia: a prospective, randomized, crossover study.
European Journal of Anaesthesiology 2009; 26: 913–6.
von Goedecke A, Voelckel WG, Wenzel V, et al. Mechanical
versus manual ventilation via a face mask during the induction
of anesthesia: a prospective, randomized, crossover study.
Anesthesia and Analgesia 2004; 98: 260–3.
Miguel-Montanes R, Hajage D, Messika J, et al. Use of high-flow
nasal cannula oxygen therapy to prevent desaturation during
tracheal intubation of intensive care patients with mild-tomoderate hypoxemia. Critical Care Medicine 2015; 43: 574–83.
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