Noninvasive ventilation vs. high-flow nasal cannula oxygen for preoxygenation before intubation in patients with obesity: a post hoc analysis of a randomized controlled trial
Authors: Rodriguez Maeva , Ragot Stéphanie , Coudroy Rémi , Quenot Jean-Pierre , Vignon Philippe , Forel Jean-Marie , Demoule Alexandre , Mira Jean-Paul , Ricard Jean-Damien , Nseir Saad , Colin Gwenhael , Pons Bertrand , Danin Pierre-Eric , Devaquet Jérome , Prat Gwenael , Merdji Hamid , Petitpas Franck , Vivier Emmanuel , Mekontso-Dessap Armand , Nay Mai-Anh , Asfar Pierre , Dellamonica Jean , Argaud Laurent , Ehrmann Stephan , Fartoukh Muriel , Girault Christophe , Robert René , Thille Arnaud W. , Frat Jean-Pierre ,   REVA Network, Chatellier Delphine , Boissier Florence , Veinstein Anne , Robert René , Dahyot-Fizelier Claire , Dargent Auguste , Large Audrey , Begot Emmanuelle , Mancia Claire , Decavele Maxence , Dres Martin , Lehingue Samuel , Papazian Laurent , Paul Marine , Marin Nathalie , Le Meur Matthieu , Laissy Mohammed , Rouzé Anahita , Henry-Lagarrigue Matthieu , Yehia Aihem , Martino Frédéric , Cerf Charles , Bailly Pierre , Helms Julie , Putegnat Jean Baptiste , Razazi Keyvan , Boulain Thierry , Asfar Pierre , Cabasson Séverin , Wallet Florent , Klouche Kada , Bellec Frédéric 
Published: July 2021

Abstract
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)