Pre- and Apnoeic High Flow Oxygenation for RApid Sequence Intubation in The Emergency Department (Pre-AeRATE): a Multicentre Randomised Controlled Trial
Phase: NA
Conditions: Intubation, Oxygen Inhalation Therapy
Sponsor: National University Hospital, Singapore

Pre-AeRATE Trial 
Protocol v2.0 Dated 29 Dec 2017  
 
 
 
 
Study Title:  
Pre- and Apnoeic high flow oxygenation for RApid sequence 
intubation in The Emergency dept (Pre-AeRATE)  
 
Principal Investigator: Dr Chua Mui Teng 
 
 
Version Number: v2.0 
29 December 2017 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pre-AeRATE Trial 
Protocol v2.0 Dated 29 Dec 2017  
 
 
 
Table of Contents  
 
1. KEY ROLES  
2. INTRODUCTION: BACKGROUND INFORMATION AND CLINICAL SIGNIFICANCE  
2.1 Background information and clinical significance 
2.2 Potential Risks and Benefits  
3. AIMS AND HYPOTHESES  
4. STUDY DESIGN AND ENDPOINTS 
4.1 Description of Study Design  
4.2 Study Endpoints 
4.2.1 
Primary Endpoint  
4.2.2 
Secondary Endpoint  
5. STUDY ENROLMENT 
5.1 Patient Inclusion Criteria  
5.2 Patient Exclusion Criteria  
6. STUDY DEVICE 
7. STUDY PROCEDURES  
8. STATISTICAL CONSIDERATION 
8.1 Sample Size  
8.2 General Approach 
9. DATA HANDLING AND RECORD KEEPING  
10. CONFLICT OF INTEREST  
11. REFERENCES  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pre-AeRATE Trial 
Protocol v2.0 Dated 29 Dec 2017  
 
 
 
1. KEY ROLES 
 
Principal Investigator 
Name: Dr Chua Mui Teng  
Degree: M.B.B.S (Singapore), MCEM (UK), M.Med (EM) (Singapore), MPH  
Title: Dr 
Institution Name: National University Hospital, Singapore 
Address: 5 Lower Kent Ridge Road, Singapore 119074 
Phone Number: +65 6779 5555 
Email: mui_teng_chua@nuhs.edu.sg 
 
Co- Investigator  
Name: Dr Kuan Win Sen  
Degree: M.B.B.S (Singapore), MRCS (A&E) (Edin), MCI 
Title: Dr 
Institution Name: National University Hospital, Singapore 
Address: 5 Lower Kent Ridge Road, Singapore 119074 
Phone Number: +65 6772 2542 
Email: win_sen_kuan@nuhs.edu.sg 
 
Co- Investigator  
Name: Dr Yau Ying Wei  
Degree: M.B.B.S (Singapore), MCEM (UK), M.Med (EM) (Singapore) 
Title: Dr 
Institution Name: National University Hospital, Singapore 
Address: 5 Lower Kent Ridge Road, Singapore 119074 
Phone Number: +65 6779 5555 
Email: ying_wei_yau@nuhs.edu.sg 
 
 
Co- Investigator  
Name: Dr Matthew Low Jian Wen 
Degree: M.B.B.S (Singapore) 
Title: Dr 
Institution Name: National University Hospital, Singapore 
Address: 5 Lower Kent Ridge Road, Singapore 119074 
Phone Number: +65 6779 5555 
Email: matthew_low@nuhs.edu.sg 
 
Co- Investigator/ Site PI  
Name: Dr Amila Clarence Anthony Clarence Charles Yudishtira PUNYADASA 
Degree: MB BCh BAO, MRCSEd, M.Med (EM) (Singapore), FCEM, FAMS 
Title: Adjunct Assistant Professor 
Institution Name: Ng Teng Fong General Hospital, Singapore 
Address: C/o Office of Amila Punyadasa, Emergency Department Offices 2, Level 1 Tower B, Ng Teng Fong 
General Hospital, 1 Jurong East Street 21, Singapore 609606 
Phone Number: +65 6716 2000 
Email: amila_punyadasa@juronghealth.com.sg 
 
 
 

Pre-AeRATE Trial 
Protocol v2.0 Dated 29 Dec 2017  
 
 
Co- Investigator 
Name: Dr Faheem Ahmed Khan   
Degree: MBBS(IND), MCEM(UK), FCEM(UK), FFICM(UK), EDIC(EUR), FAMS  
Title: Dr 
Institution Name: Ng Teng Fong General Hospital, Singapore 
Address: Department of Intensive Care medicine, 1 Jurong East Street 21, Singapore 609606 
Phone Number: +65 6716 2000 
Email: faheem_ahmed_khan@juronghealth.com.sg 
 
Collaborator  
Name: Dr Lu Qingshu 
Degree: BS, PhD 
Title: Dr 
Institution Name: Singapore Clinical Research Institute (SCRI), Singapore 
Address: 31 Biopolis Way Nanos #02-01 Singapore 138669 
Phone Number: +65 6508 6753 
Email: qingshu.lu@scri.edu.sg 
 
Collaborator 
Name: Dr Matthew Edward Cove  
Degree: BSc. (Hons), MBChB 
Title: Dr 
Institution Name: National University Hospital, Singapore 
Address: Department of Medicine, NUHS Tower Block, Level 10, 1E Kent Ridge Road 
Singapore 119228 
Phone Number: +65 6772 7678 
Email: mdcmec@nus.edu.sg 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pre-AeRATE Trial 
Protocol v2.0 Dated 29 Dec 2017  
 
 
2. 
INTRODUCTION: BACKGROUND INFORMATION AND CLINICAL SIGNIFICANCE 
 
2.1 Background information and clinical significance 
Rapid sequence intubation (RSI) is the most common method of intubation used in the ED.1 RSI involves the 
immediate administration of a paralytic agent following delivery of an induction agent that brings about 
unresponsiveness; a procedure which aims for successful endotracheal intubation with no ventilation via bag-
valve-mask while awaiting the onset of paralysis. Under these circumstances, the maintenance of oxygen 
saturation during the apnoeic phase depends on the patient’s underlying oxygen reserve, the adequacy of 
pre-oxygenation and the ability to insufflate the apnoeic lungs with oxygen (apnoeic oxygenation).  
Critically ill patients have shorter safe apnoeic time (defined as duration of apnoea where SpO2 remains ≥ 
90%2) due to physiological stressors that accompany critical illnesses, such as decreased cardiac output, 
increased shunting and reduced pulmonary reserves. Once the SpO2 reading approaches 90%, it can rapidly 
drop to < 70% (a critical hypoxic state) within seconds3 for two reasons. Firstly, a SpO2 of 90% represents the 
steep gradient of the oxygen dissociation curve (Figure 1), where a small change in the arterial partial 
pressure of oxygen (PaO2) results in a large change in haemoglobin oxygen binding capacity.4 Secondly, the 
pulse oximeter devices routinely used to measure SpO2 have dampened circuitry to prevent fluctuating 
readings. However, this property may delay recognition of falling haemoglobin oxygen saturation5 and up to 
47% of patients may experience latency in SpO2 readings of up to 2 minutes.6 Furthermore, with increasing 
prevalence of obesity in Singapore7 from increasing affluence, a large proportion of our critically ill patients are 
also obese, and obesity can further shorten safe apnoeic times. Benumof et al. estimated that a moderately ill 
normal-sized adult would reach an SpO2 of 90% at slightly under 5 minutes, while a 127kg obese adult would 
reach such a level within 2.5 to 3 minutes8 (Figure 2).  
Profound hypoxaemia during intubation results in higher proportions of peri-intubation cardiac arrest, brain 
injury and death.3,9The risk of adverse outcomes escalates with increasing number of attempts at 
endotracheal intubation and with development of hypoxia.10–12 Prolongation of safe apnoea time would 
ameliorate some of these negative outcomes, by preventing hypoxia and allowing more time to achieve 
successful intubation without resorting to bag-mask ventilation to re-oxygenate the patient. 
Adequate pre-oxygenation is the cornerstone of successful RSI and an essential step to achieving prolonged 
safe apnoeic times during intubation.2 Pre-oxygenation with high fraction of inspired oxygen (FiO2) de-
nitrogenates the lungs, maximises oxygen reserve and oxygen saturation in the bloodstream.3 The standard 
of care is to apply a non-rebreather mask (NRM) with tidal volume breathing for 3 minutes for pre-
oxygenation. However, depending on the patients respiratory rate and depth of breathing (i.e. their minute 
volume) the actual FiO2 delivered varies from 0.8 to 0.6,13 sometimes even lower. Other more efficacious 
methods such as applying positive airway pressure and pre-oxygenating in a head-up position of 20 degrees 
have been described, but are not always possible in emergency situations or with obtunded patients.14,15 
High flow nasal cannula (HFNC) oxygenation has been gaining interest as an alternative method of pre-
oxygenation and apnoeic oxygenation.16 It can deliver up to 60L/min of oxygen and FiO2 of 1.0. As it is 
 
Figure 1. Oxyhaemoglobin dissociation curve of a healthy 
individual
4 
Figure 2. Arterial oxyhaemoglobin saturation (SaO2) versus 
time of apnoea in an obese adult, a 10kg, and in a 
moderately ill adult, compared with a healthy adult. FAO2 , 
Fractional alveolar oxygen concentration; VE, expired 
volume
7 

Pre-AeRATE Trial 
Protocol v2.0 Dated 29 Dec 2017  
 
 
humidified and heated, the high flow is well tolerated by awake patients.17 Moreover, the high flow has been 
shown to wash out carbon dioxide in anatomical dead space, create positive airway pressure adequate 
enough for alveolar recruitment and maintain a constant FiO2, regardless of the patient’s minute volume.16 
Additionally, it has the convenience of continuing oxygenation during the apnoeic phase after induction and 
paralysis, since the high flow maintains a positive end expiratory pressure and can insufflate the lungs, 
resulting in apnoeic oxygenation. Apnoeic oxygenation is possible due to differential solubility of oxygen and 
carbon dioxide in blood. Carbon dioxide is more soluble and therefore moves less readily down its 
concentration gradient from the bloodstream into the alveoli during apnoea. As a result, more oxygen moves 
from the alveoli into the bloodstream. This creates a sub-atmospheric pressure in the alveoli, allowing oxygen 
to flow from the pharynx to the alveoli during apnoea. Despite this sensible physiological rationale, a recent 
large randomised controlled trial reported no difference in median lowest arterial oxygen saturation in ICU 
patients with apnoeic oxygenation using 15L/min of nasal cannula compared with no apnoeic oxygenation at 
all.18 However, limitations in this study prevent definitive conclusions to be drawn. Firstly, the oxygen flow of 
15L/min was delivered through routine nasal cannulae, which are not designed for such flows. Secondly, a 
flow rate of 15L/min may not be high enough to provide apnoeic oxygenation. It has been shown that flows of 
30L/min are necessary to generate positive airway pressures.19 Thirdly, the cohort in the study consisted of 
mostly medical ICU patients with advanced respiratory failure, where 15L/min of oxygenation may not 
generate enough positive airway pressure to overcome pulmonary shunting. Furthermore, the results cannot 
be generalised to patients who do not typically present to medical ICUs, for instance patients with severe 
trauma or a surgical diagnosis.
There have been conflicting results from previous studies evaluating pre-oxygenation and apnoeic 
oxygenation using true HFNC. The PREOXYFLOW trial is the largest randomised controlled trial (RCT) to 
date (n=124) and found no difference in the lowest SpO2 achieved when HFNC oxygenation was compared to 
high fraction-inspired oxygen facial mask for pre-oxygenation.20 These results differ from another quasi-
experimental before-after study (n=101), which showed that patients who were pre-oxygenated with HFNC 
had significantly higher SpO2 during the apnoeic phase.21 Both studies were conducted in ICU patients and 
continued the HFNC during the apnoeic phase for apnoeic oxygenation. In addition to the contradictory 
findings by the 2 studies, it is also difficult to conclude whether the favourable results were attributable to the 
effect of HFNC during pre-oxygenation or apnoeic oxygenation. 
Until now, there have been no studies conducted in the ED investigating the use of HFNC for pre- and 
apnoeic oxygenation. The incidence of failed intubations in the emergency setting is estimated to be 20 times 
that compared to intubation done electively22 and ED patients differ from ICU patients because they are less 
likely to have been fasted, increasing the risk of aspiration if re-oxygenation with bag valve mask is required 
during the intubation attempts. Aspiration of gastric contents contributes to increased risk of death during 
intubation.23 Furthermore, hypoxia from failure to intubate is associated with increased ICU length of stay, 
irreversible brain damage, increased number of ventilated days and higher incidence of tracheostomy.24 This 
translates to longer hospital stays, adversely affecting overall bed occupancy, as well as higher healthcare 
costs. Given the existing high occupancy in Singapore’s restructured hospitals, which is expected to worsen 
as the population ages, it is vital that we prevent such adverse events from occurring by prolonging safe 
apnoea times for intubation (i.e. maintain lowest SpO2 above 90%), without the need for bag-valve-mask 
ventilation for re-oxygenation during RSI. If our hypothesis is confirmed, the results from this study could 
potentially change current clinical practice and reduce demands on an already stressed healthcare system. 
 
2.2 Potential benefits and risks  
 
Potential benefits include a longer safe apnoeic time during rapid sequence intubation (i.e. SpO2 maintains 
more than or equal to 90% after intubation til successful intubation). Although well tolerated by most patients, 
delivering HFNC oxygenation may have the following side effects or risks such as:  

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Pre-AeRATE Trial 
Protocol v1.0 Dated 14 May 2017  
 
Allocation concealment will be maintained until registration and randomisation process is completed. 
However, due to the nature of the intervention, it will not be possible to blind the treating clinician, ED staff 
members or patient after allocation has occurred. A possible concern is whether the results will be biased due 
to lack of blinding. As the outcome measures in our study are objective physiological measurements, the risk 
of bias remains low.27 Clinicians in the admitting ICU will be blinded to the patients’ allocation to any of the 
study arms. 
Treatment protocol 
In the intervention arm, the patients will receive oxygenation with 60L/min using the AIRVO™ 2 Humidifier 
with Integrated Flow Generator (Fisher & Paykel Healthcare, Auckland, New Zealand) during the pre- and 
apnoeic oxygenation phases.  
The control group will be managed in accordance with current best practice by performing pre-oxygenation 
using NRM that has a FiO2 of 0.6 to 0.813 and given 15L/min of oxygen via nasal cannula (non-humidified, 
from wall supply). 
Both groups will receive 3 minutes of pre-oxygenation.3,28,29 Premedication (if required) will be given 3 minutes 
prior to RSI, i.e. at the start of pre-oxygenation.30 The lowest SpO2 achieved from time of administration of 
paralytic agent until quantitative end-tidal CO2 (ETCO2) is detected for the first intubation attempt will be 
measured for all groups, together with the variables listed below.  
 
4.2 Study endpoints  
 
1. Primary endpoint 
• 
Lowest SpO2 achieved during first intubation attempt 
o 
From time of administration of paralytic agent until quantitative ETCO2 is detected post-intubation  
o 
First intubation attempt is defined as first attempt to insert endotracheal tube into oropharynx 
SpO2 will be measured using the pulse oximeter of Philips Intellivue MP30 Patient Monitor.  
 
2. Secondary endpoints 
• 
Number of attempts at intubation  
• 
Safe apnoea time during intubation 
• 
Incidence of SpO2 < 90% 
• 
Peri-intubation adverse events (see below under Study Procedures)  
• 
Length of time to successful intubation 
• 
Incidence of ventilator associated pneumonia and aspiration pneumonia 
• 
Number of ventilated days 
• 
In-hospital mortality in ICU and on discharge  
• 
Highest Sequential Organ Failure Assessment (SOFA) score 
• 
Incidence of acute respiratory distress syndrome (ARDS) 
• 
Lowest PaO2 : FiO2 ratio while intubated 
 
5.          STUDY ENROLMENT AND WITHDRAWAL  
5.1 Inclusion criteria  
Adult patients aged 21 years and above, who require RSI due to medical, surgical and traumatic conditions, in 
the Emergency Departments of National University Hospital will be eligible for study enrolment.  
 
5.2 Exclusion criteria  
• 
Patients with “do-not-resuscitate” orders 
• 
Crash, awake or delayed sequence intubations 
• 
Patients requiring non-invasive positive pressure ventilation 
• 
Cardiac arrest  
• 
Clinical suspicion or confirmed diagnosis of base of skull fractures or severe facial trauma that 
precludes nasal cannula placement 

Pre-AeRATE Trial 
Protocol v1.0 Dated 14 May 2017  
 
• 
Vulnerable patient populations (e.g. pregnant women, prisoners) 
 
6.          STUDY DEVICE 
 
In the treatment group for pre- and apnoeic oxygenation using HFNC, the patients will be pre-oxygenated and 
oxygenated during apnoea with 60L/min of warm and humidified oxygen using the AIRVO™ 2 Humidifier with 
Integrated Flow Generator (Fisher & Paykel Healthcare, Auckland, New Zealand). 
 
 
 
7.          STUDY PROCEDURES 
 
Method of oxygenation for each patient will be dependent on the treatment combination randomised and 
assigned as described above.  
Patients will be pre-oxygenated for 3 minutes with 60L/min using the AIRVO™ 2 Humidifier with Integrated 
Flow Generator or non-rebreather mask depending on treatment group randomised to. Premedication (if 
required) will be given 3 minutes prior to RSI, i.e. at the start of pre-oxygenation. Once 3 minutes of pre-
oxygenation is completed, induction medications are administered and apnoeic oxygenation commenced as 
per assigned treatment group, which comprised of nasal cannula oxygenation at 15L/min or HFNC at 
60L/min. Intubation attempts starts after 30 to 45 seconds (onset time of paralytic agent, typically 
succinylcholine or rocuronium). If the intubator is of resident grade, only 2 attempts are allowed before 
escalating to an EM specialist. Each attempt is defined as passage of laryngoscope through mouth.  
End of intubation is defined as placement of endotracheal tube with confirmation of placement using 
quantitative end-tidal CO2. 
 
Clinical data collected (with no identifying data) will include: 
(a) Pre-
oxygenation 
 
• 
Time pre-oxygenation started 
• 
Position adopted for pre-oxygenation 
• 
Duration of pre-oxygenation (time of induction = end of pre-oxygenation) 
• 
SpO2 at beginning and end of pre-oxygenation (i.e. prior to induction) 
• 
Mode of pre-oxygenation (HFNC, NRM)  
• 
Lowest SpO2 during pre-oxygenation 
• 
Name, dosages and timing of pre-medications given 
(b) Intubation 
• 
Time induction agent given, name of induction agent and dose  
• 
Time paralytic agent given, name of paralytic agent and dose 
• 
Time of successful intubation  
• 
Lowest SpO2 achieved during subsequent intubation attempts (if 
unsuccessful at 1st attempt)  
• 
SpO2 at the end of intubation  
• 
Type of laryngoscope use (direct/ articulating/ video)  
• 
Adjunct devices use (e.g. bougie)  
• 
Position of intubation 
• 
Cormack-Lehane scoring of laryngeal view (state direct or video view)  
• 
Intubator speciality and level of experience (by post-graduate year)  
• 
Supervision by EM specialist (yes/no)  
• 
Peri-intubation adverse events: hypotension, hypertension, tachycardia, 
bradycardia, regurgitation, aspiration, cardiac arrhythmia, cardiac arrest 
during RSI, oropharynx or dental trauma 
 
 
Figure 4. (a) Image of AIRVO™ 2 Humidifier with Integrated Flow 
Generator (left); (b) Nasal cannula interface (middle); and (c) heating 
tube (right). 
Figure 5: Image showing how the nasal cannula will be 
connected to the AIRVO™ 2 system and patient. 

Pre-AeRATE Trial 
Protocol v1.0 Dated 14 May 2017  
 
(c) Clinical 
outcomes 
• 
Length of stay in ICU  
• 
As in secondary endpoints 
(d) Difficult airway 
features 
• 
Reduced neck mobility or on C collar  
• 
Mallampati score  
• 
Mouth opening  
• 
Thyromental distance  
• 
Airway obstruction  
• 
Facial trauma (if not severe enough to preclude recruitment as per exclusion 
criteria) 
• 
Blood or vomitus in airway  
(e) Others 
 
• 
Demographics (age, gender, ethnicity, body mass index)  
• 
Comorbid conditions (congestive cardiac failure, ischemic heart disease, 
atrial fibrillation, chronic renal disease, chronic obstructive pulmonary 
disease, asthma, obstructive sleep apnoea, diabetes, previous head and 
neck radiation, head and neck mass or infection, upper gastrointestinal 
bleeding) 
• 
Pre-intubation vital signs (temperature, heart rate, systolic BP, diastolic BP, 
mean arterial pressure, Glasgow Coma Scale) 
• 
Quick SOFA score at triage and prior to pre-oxygenation 
• 
CXR findings  
• 
Indication for intubation 
• 
Vasopressor use 
 
Only the index ED visit is included in the study. There will be no repeat visits. Patients’ clinical outcomes as 
per secondary endpoints will be followed up electronically from the Computerised Patients’ Support System 
(CPSS-2)  
  
8.          STATISTICAL CONSIDERATION  
 
8.1 Sample size calculation 
Based on our preliminary data and previous studies, we anticipate a standard deviation of 14% in lowest 
SpO2. Enrolment of 184 patients (92 patients in each of control and intervention groups) will provide 
statistical power of 80% (with a two-sided α of 0.05) to detect a 6% difference in lowest SpO2, allowing for a 
5% dropout.  
 
8.2 General approach for statistical analysis 
The primary analysis will be an intention-to-treat analysis, comparing the primary outcome of lowest SpO2 
achieved between two groups. Descriptive statistics of lowest SpO2 (e.g. mean, standard deviation, median 
and interquartile range) will be reported for each group. Comparison of mean (or median) lowest SpO2 
between groups will be made using two-sample t-test or non-parametric test as appropriate. 95% confidence 
intervals of difference in lowest SpO2 will be provided. Categorical data will be compared using the Fisher’s 
exact test. We will use linear and logistic regression to adjust our findings if there are important differences 
between the study arms that might confound the results. 
 
9.          DATA HANDLING AND RECORD KEEPING 
 
The Research Electronic Data Capture (REDCap) system will be used and maintained at SCRI’s secure 
server. Authorised personnel will be assigned user IDs and passwords to gain access to the database. 
Entered data will be systematically checked by built-in edit checks. 
 
The study participant’s information and research data will be securely stored at the dedicated research 
computers in the NUH and NTFGH Emergency Departments for internal use during the study. The research 
computers are password protected and located in the Emergency Department administrative offices which are 
only accessible to authorised personnel by card access. Individual participants and their research data will be 
identified by a unique study identification number. Patients’ identifiers and research data will be stored 
separately.  
 

Pre-AeRATE Trial 
Protocol v1.0 Dated 14 May 2017  
 
 
10.        CONFLICT OF INTEREST  
 
The PI and co-investigators declare no conflict of interests.  
 
 
11.        REFERENCES  
 
1.  
Walls RM, Brown CA, Bair AE, Pallin DJ. Emergency airway management: a multi-center report of 
8937 emergency department intubations. J Emerg Med. 2011;41(4):347-354. 
2.  
Thorpe CM, Gauntlett IS. Arterial oxygen saturation during induction of anaesthesia . Anaesthesia. 
1990;45:1012-1015. 
3.  
Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway 
management.. Ann Emerg Med. 2012;59:165-175. 
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