High-flow Nasal Cannulae Versus Non-invasive Ventilation for Preoxygenation of Obese Patients: The PREOPTIPOP Randomized Trial

Mickael Vourc'h, Gabrielle Baud, Fanny Feuillet, Claire Blanchard, Eric Mirallie, Christophe Guitton, Samir Jaber, Karim Asehnoune, Mickael Vourc'h, Gabrielle Baud, Fanny Feuillet, Claire Blanchard, Eric Mirallie, Christophe Guitton, Samir Jaber, Karim Asehnoune

Abstract

Background: In obese patients, preoxygenation with non-invasive ventilation (NIV) was reported to improve outcomes compared with facemask. In this setting, high-flow nasal cannulae (HFNC) used before and during intubation has never been studied against NIV.

Methods: The PREOPTIPOP study is a randomised, single-centre, open-labelled, controlled trial including obese patients requiring intubation before scheduled surgery. Patients were randomised to receive preoxygenation by HFNC or NIV. HFNC was maintained throughout intubation whereas NIV was removed when apnea occurred to perform laryngoscopy. The study was designed to assess the superiority of HNFC. The primary outcome was the lowest level of end-tidal oxygen concentration (EtO2) within 2 min after intubation. Secondary outcomes included drop in pulse oximetry and complications related to intubation.

Main findings: A total of 100 patients were randomised. The intent-to-treat analysis found median [IQR] lowest EtO2 of 76% [66-82] for HFNC and 88% [82-90] for NIV (mean difference - 12·1 [- 15·1 to - 8·5], p < 0·0001). Mild desaturation below 95% was more frequent with HFNC (30%) than with NIV (12%) (relative risk 2·5, IC 95% [1·1 to 5·9], p = 0·03) and median lowest SpO2 during intubation was 98% [93-99] in HFNC vs. 99% [97-100] in NIV (p = 0·03). Severe and moderate complications were not different but patients reported more discomfort with NIV (28%) vs. HFNC (4%), p = 0·001.

Interpretation: Compared with NIV, preoxygenation with HFNC in obese patients provided lower EtO2 after intubation and a higher rate of desaturation < 95%.

Funding: Institutional funding, additional grant from Fisher & Paykel.

Trial registration: Clinical trial Submission: April 10, 2017. Registry name: Preoxygenation Optimization in Obese Patients: High-flow Nasal Cannulae Oxygen Versus Non-invasive Ventilation: A Single-centre Randomised Controlled Study. The PREOPTIPOP Study. Clinicaltrials.gov identifier: NCT03106441 N°ID RCB: 2017-A00305-48. Institutional review Board: CPP Nord-Ouest I, registration number 019/2017. URL registry:https://ichgcp.net/clinical-trials-registry/NCT03106441.

Keywords: Apnoeic oxygenation; High-flow oxygen therapy by nasal cannulae; Intubation; Morbid obesity; Non-invasive ventilation; Preoxygenation.

Conflict of interest statement

Fanny Feuillet, Claire Blanchard, Eric Miraille and Christophe Guitton declare no conflict of interest. Mickael Vourc'h declares personal fees from MSD, Pfizer, Baxter and grants from Fischer Paykel, outside the submitted work. Samir Jaber reports personal fees from Draeger, Fresenius-Xenios and Fisher Paykel Healthcare, outside the submitted work. Karim Asehnoune declares personal fees from Fisher Paykel Healthcare, Baxter, LFB, Fresenius.

Figures

Fig. 1
Fig. 1
Study design During preoxygenation (FiO2 100%), EtO2 (Green line) increases and reflects the partial pressure of oxygen in the lung (PAO2). During apnoea, (Dotted green line) the value of EtO2 is not available because the patient does not exhale gas. After intubation, EtO2 decreases (Green line) to its lowest value then increases because the lung refills with FiO2 100% (set on ventilator). IPAP: Inspiratory positive airway pressure (cm of water), EPAP: Expiratory positive airway pressure (cm of water), EtO2: End-tidal oxygen concentration was collected until two minutes following intubation because the measurement can be delayed by 35 s (manufacturer instructions). In order to limit measurement fluctuations, fresh gas flow was set at 1 L/min. FiO2: Fraction of inspired oxygen, NIV: Non-invasive ventilation, HFNC: High flow oxygenation by nasal cannulae, RR: Recovery room.
Fig. 2
Fig. 2
Study flow chart HFNC: High-flow nasal cannulae, NIV: Non-invasive ventilation, ITT: Intent-to-treat analysis, SpO2: Level of oxygen saturation measured by pulse oximetry.
Fig. 3
Fig. 3
Primary outcome: lowest EtO2 in the 2 min following intubation HFNC: high-flow nasal cannulae, NIV: Non-invasive ventilation, ITT: intent-to-treat analysis, IQR: interquartile range, EtO2: End-tidal oxygen concentration.

References

    1. Kopelman P., Jebb S.A., Butland B. Executive summary: foresight ‘tackling obesities: future choices’ project. Obes Rev. 2007;8(Suppl. 1):vi–ix.
    1. Cook T.M., Woodall N., Frerk C. Fourth National Audit Project. 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. Br J Anaesth. 2011;106:617–631.
    1. Damia G., Mascheroni D., Croci M., Tarenzi L. Perioperative changes in functional residual capacity in morbidly obese patients. Br J Anaesth. 1988;60:574–578.
    1. De Jong A., Molinari N., Pouzeratte Y. Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units. Br J Anaesth. 2015;114:297–306.
    1. Jense H.G., Dubin S.A., Silverstein P.I., O'Leary-Escolas U. Effect of obesity on safe duration of apnea in anesthetized humans. Anesth Analg. 1991;72:89–93.
    1. Juvin P., Lavaut E., Dupont H. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97:595–600. [tableofcontents]
    1. Nightingale C.E., Margarson M.P. Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia. Anaesthesia. 2015;70:859–876.
    1. Checketts M.R., Alladi R., Ferguson K. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2016;71:85–93.
    1. Futier E., Constantin J.-M., Pelosi P. Noninvasive ventilation and alveolar recruitment maneuver improve respiratory function during and after intubation of morbidly obese patients: a randomized controlled study. Anesthesiology. 2011;114:1354–1363.
    1. Delay J.-M., Sebbane M., Jung B. The effectiveness of noninvasive positive pressure ventilation to enhance preoxygenation in morbidly obese patients: a randomized controlled study. Anesth Analg. 2008;107:1707–1713.
    1. Gander S., Frascarolo P., Suter M., Spahn D.R., Magnusson L. Positive end-expiratory pressure during induction of general anesthesia increases duration of nonhypoxic apnea in morbidly obese patients. Anesth Analg. 2005;100:580–584.
    1. Parke R., McGuinness S., Eccleston M. Nasal high-flow therapy delivers low level positive airway pressure. Br J Anaesth. 2009;103:886–890.
    1. Jaber S., Monnin M., Girard M. Apnoeic oxygenation via high-flow nasal cannula oxygen combined with non-invasive ventilation preoxygenation for intubation in hypoxaemic patients in the intensive care unit: the single-centre, blinded, randomised controlled OPTINIV trial. Intensive Care Med. 2016;42:1877–1887.
    1. Patel A., Nouraei S.A.R. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015;70:323–329.
    1. Frerk C., Mitchell V.S., McNarry A.F. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults†. Br J Anaesth. 2015;115:827–848.
    1. Mort T.C. Preoxygenation in critically ill patients requiring emergency tracheal intubation. Crit Care Med. 2005;33:2672–2675.
    1. Baillard C., Fosse J.-P., Sebbane M. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 2006;174:171–177.
    1. Grmec S. Comparison of three different methods to confirm tracheal tube placement in emergency intubation. Intensive Care Med. 2002;28:701–704.
    1. Adnet F., Borron S.W., Racine S.X. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology. 1997;87:1290–1297.
    1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway Practice guidelines for management of the difficult airway: an updated report. Anesthesiology. 2003;98:1269–1277.
    1. Arozullah A.M., Khuri S.F., Henderson W.G., Daley J. Participants in the National Veterans Affairs Surgical Quality Improvement Program. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med. 2001;135:847–857.
    1. Heinrich S., Horbach T., Stubner B., Prottengeier J., Irouschek A., Schmidt J. Benefits of heated and humidified high flow nasal oxygen for preoxygenation in morbidly obese patients undergoing bariatric surgery: a randomized controlled study. J Obes Bariatric. 2015;1
    1. Ramachandran S.K., Cosnowski A., Shanks A., Turner C.R. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth. 2010;22:164–168.
    1. Corley A., Caruana L.R., Barnett A.G., Tronstad O., Fraser J.F. Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. Br J Anaesth. 2011;107:998–1004.
    1. Mort T.C. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99 [607–13–tableofcontents]
    1. Langeron O., Bourgain J.-L., Francon D. Difficult intubation and extubation in adult anaesthesia. Anesth Réanim. 2017;3:552–571.
    1. Button K.S., Ioannidis J.P.A., Mokrysz C. Power failure: why small sample size undermines the reliability of neuroscience. Nat Rev Neurosci. 2013;14:365–376.
    1. Demirkaya M., Kelsaka E., Sarihasan B., Bek Y., Üstün E. The optimal dose of remifentanil for acceptable intubating conditions during propofol induction without neuromuscular blockade. J Clin Anesth. 2012;24:392–397.
    1. Bouvet L., Stoian A., Rimmelé T., Allaouchiche B., Chassard D., Boselli E. Optimal remifentanil dosage for providing excellent intubating conditions when co-administered with a single standard dose of propofol. Anaesthesia. 2009;64:719–726.
    1. Vourc'h M., Asfar P., Volteau C. High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: a randomized controlled clinical trial. Intensive Care Med. 2015:1–11.
    1. Perkins G.D., McAuley D.F., Giles S., Routledge H., Gao F. Do changes in pulse oximeter oxygen saturation predict equivalent changes in arterial oxygen saturation? Crit Care. 2003;7 R67–7.
    1. Szmuk P., Steiner J.W., Olomu P.N., Ploski R.P., Sessler D.I., Ezri T. Oxygen reserve index: a novel noninvasive measure of oxygen reserve—a pilot study. Anesthesiology. 2016;124:779–784.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj