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DeMasi et al. published a review on the current evidence surrounding peri-intubation and intubation practices. While the actual approach and context to each patient will be different it is good to be aware of the actual evidence base for medical decision-making.
Preoxygenation
- NIPPV appears to decrease hypoxemia in all subgroups (including in those not requiring supplemental O2 prior to enrollment)
- PREOXI trial
- Data for HFNC over NRB is inconclusive
Between Induction and Laryngoscopy
- BVM decreased hypoxemia vs. no-ventilation, without a higher risk of aspiration
- PreVent trial
During Laryngoscopy and Intubation of the Trachea
- Apneic oxygenation may increase the lowest oxygen saturation, but a much smaller benefit than pre-induction PPV
Medications
- Induction
- Still uncertainty re: differences in patient-centered outcomes for etomidate vs. ketamine
- NMB
- No rigorous evidence for rocuronium vs. succinylcholine (if no contraindications)
Interventions to Prevent Hypotension
- Peri-intubation IVF boluses have not been shown to prevent hypotension, need for pressors, or cardiac arrest
- Reasonable to have prophylactic vasopressors running or available, but evidence of potential serious dosing errors for push-dose
References
DeMasi SC, Casey JD, Semler MW. Evidence-based emergency tracheal intubation. Am J Respir Crit Care Med. Published online April 16, 2025.