Abstract
BackgroundCritically ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia. We hypothesized that pre-oxygenation with noninvasive ventilation before intubation as compared with high-flow nasal cannula oxygen may decrease the risk of severe hypoxemia in patients with obesity.MethodsPost hoc subgroup analysis of critically ill patients with obesity (body mass index ≥ 30 kg·m−2) from a multicenter randomized controlled trial comparing preoxygenation with noninvasive ventilation and high-flow nasal oxygen before intubation of patients with acute hypoxemic respiratory failure (PaO2/FiO2 < 300 mm Hg). The primary outcome was the occurrence of severe hypoxemia (pulse oximetry < 80%) during the intubation procedure.ResultsAmong the 313 patients included in the original trial, 91 (29%) had obesity with a mean body mass index of 35 ± 5 kg·m−2. Patients with obesity were more likely to experience an episode of severe hypoxemia during intubation procedure than patients without obesity: 34% (31/91) vs. 22% (49/222); difference, 12%; 95% CI 1 to 23%; P = 0.03. Among patients with obesity, 40 received preoxygenation with noninvasive ventilation and 51 with high-flow nasal oxygen. Severe hypoxemia occurred in 15 patients (37%) with noninvasive ventilation and 16 patients (31%) with high-flow nasal oxygen (difference, 6%; 95% CI − 13 to 25%; P = 0.54). The lowest pulse oximetry values during intubation procedure were 87% [interquartile range, 77–93] with noninvasive ventilation and 86% [78–92] with high-flow nasal oxygen (P = 0.98). After multivariable analysis, factors independently associated with severe hypoxemia in patients with obesity were intubation difficulty scale > 5 points and respiratory primary failure as reason for admission.ConclusionsPatients with obesity and acute hypoxemic respiratory failure had an increased risk of severe hypoxemia during intubation procedure as compared to patients without obesity. However, preoxygenation with noninvasive ventilation may not reduce this risk compared with high-flow nasal oxygen.Trial registration Clinical trial number: NCT02668458 (http://www.clinicaltrials.gov)
Highlights
Ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia
Comparison between patients with and without obesity Among the 313 patients included in the original trial, 91 (29%) patients had obesity with a mean body mass index of 35 ± 5 kg·m−2
Patients with obesity were more likely to experience an episode of severe hypoxemia during intubation procedure than patients without obesity: 34% (31 out of 91 patients) vs. 22% (49 out of 222) (Fig. 1)
Summary
Ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia. Methods: Post hoc subgroup analysis of critically ill patients with obesity (body mass index ≥ 30 kg·m−2) from a multicenter randomized controlled trial comparing preoxygenation with noninvasive ventilation and high-flow nasal oxygen before intubation of patients with acute hypoxemic respiratory failure (PaO2/FiO2 < 300 mm Hg). Preoxygenation with noninvasive ventilation seemed to decrease this risk in moderate-to-severe hypoxemic patients [24] From this large-scale clinical trial, we performed a post hoc analysis to determine whether critically ill patients with obesity had an increased risk of severe hypoxemia during intubation procedure and whether noninvasive ventilation as compared to high-flow nasal oxygen may prevent severe hypoxemia in this subgroup. We tested in a post hoc analysis the hypothesis that pre-oxygenation with noninvasive ventilation before intubation as compared with high-flow nasal oxygen may decrease the risk of severe hypoxemia in patients with obesity
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