2019 Feb 28 - Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults
Jonathan D. Casey, M.D., David R. Janz, M.D., Derek W. Russell, M.D., Derek J. Vonderhaar, M.D., Aaron M. Joffe, D.O., Kevin M. Dischert, M.D., Ryan M. Brown, M.D., Aline N. Zouk, M.D., Swati Gulati, M.B., B.S., Brent E. Heideman, M.D., Michael G. Lester, M.D., Alexandra H. Toporek, M.D., Itay Bentov, M.D., Ph.D., Wesley H. Self, M.D., Todd W. Rice, M.D., and Matthew W. Semler, M.D. for the PreVent Investigators and the Pragmatic Critical Care Research Group
N Engl J Med 2019; 380:811-821
BACKGROUND
Hypoxemia is the most common complication during tracheal intubation of critically ill adults and may increase the risk of cardiac arrest and death. Whether positive-pressure ventilation with a bag-mask device (bag-mask ventilation) during tracheal intubation of critically ill adults prevents hypoxemia without increasing the risk of aspiration remains controversial.
METHODS
In a multicenter, randomized trial conducted in seven intensive care units in the United States, we randomly assigned adults undergoing tracheal intubation to receive either ventilation with a bag-mask device or no ventilation between induction and laryngoscopy. The primary outcome was the lowest oxygen saturation observed during the interval between induction and 2 minutes after tracheal intubation. The secondary outcome was the incidence of severe hypoxemia, defined as an oxygen saturation of less than 80%.
RESULTS
Among the 401 patients enrolled, the median lowest oxygen saturation was 96% (interquartile range, 87 to 99) in the bag-mask ventilation group and 93% (interquartile range, 81 to 99) in the no-ventilation group (P=0.01). A total of 21 patients (10.9%) in the bag-mask ventilation group had severe hypoxemia, as compared with 45 patients (22.8%) in the no-ventilation group (relative risk, 0.48; 95% confidence interval [CI], 0.30 to 0.77). Operator-reported aspiration occurred during 2.5% of intubations in the bag-mask ventilation group and during 4.0% in the no-ventilation group (P=0.41). The incidence of new opacity on chest radiography in the 48 hours after tracheal intubation was 16.4% and 14.8%, respectively (P=0.73).
CONCLUSIONS
Among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation. (Funded by Vanderbilt Institute for Clinical and Translational Research and others; PreVent ClinicalTrials.gov number, NCT03026322.)
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