by Maeva Rodriguez, Stéphanie Ragot, Rémi Coudroy,
Jean-Pierre Quenot, Philippe Vignon, Jean-Marie Forel, Alexandre Demoule,
Jean-Paul Mira, Jean-Damien Ricard, Saad Nseir, Gwenhael Colin, Bertrand Pons,
Pierre-Eric Danin, Jérome Devaquet, Gwenael Prat, Hamid Merdji…
Annals of
Intensive Care volume 11, Article number: 114, Published: 22
July 2021
Background
Critically 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.
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). The primary outcome was
the occurrence of severe hypoxemia (pulse oximetry < 80%) during the
intubation procedure.
Results
Among 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.
Conclusions
Patients 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)
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