Protocol and statistical analysis plan for the PREOXI trial of preoxygenation with noninvasive ventilation vs oxygen mask
Authors: Gibbs Kevin W. , Ginde Adit A. , Prekker Matthew E. , Seitz Kevin P. , Stempek Susan B. , Taylor Caleb , Gandotra Sheetal , White Heath , Resnick-Ault Daniel , Khan Akram , Mohmed Amira , Brainard Jason C. , Fein Daniel G. , Aggarwal Neil R. , Whitson Micah R. , Halliday Stephen J. , Gaillard John P. , Blinder Veronika , Driver Brian E. , Palakshappa Jessica A. , Lloyd Bradley D. , Wozniak Joanne M. , Exline Matthew C. , Russell Derek W. , Ghamande Shekhar , Withers Cori , Hubel Kinsley A. , Moskowitz Ari , Bastman Jill , Andrea Luke , Sottile Peter D. , Page David B. , Long Micah T. , Goranson Jordan Kugler , Malhotra Rishi , Long Brit J. , Schauer Steven G. , Connor Andrew , Anderson Erin , Maestas Kristin , Rhoads Jillian P. , Womack Kelsey , Imhoff Brant , Janz David R. , Trent Stacy A. , Self Wesley H. , Rice Todd W. , Semler Matthew W. , Casey Jonathan D. ,   the PREOXI investigators and the Pragmatic Critical Care Research Group
Published: March 2023

ABSTRACTBackgroundHypoxemia is a common and life-threatening complication during emergency tracheal intubation of critically ill adults. The administration of supplemental oxygen prior to the procedure (“preoxygenation”) decreases the risk of hypoxemia during intubation.Research QuestionWhether preoxygenation with noninvasive ventilation prevents hypoxemia during tracheal intubation of critically ill adults, compared to preoxygenation with oxygen mask, remains uncertain.Study Design and MethodsThe PRagmatic trial Examining OXygenation prior to Intubation (PREOXI) is a prospective, multicenter, non-blinded randomized comparative effectiveness trial being conducted in 7 emergency departments and 17 intensive care units across the United States. The trial compares preoxygenation with noninvasive ventilation versus oxygen mask among 1300 critically ill adults undergoing emergency tracheal intubation. Eligible patients are randomized in a 1:1 ratio to receive either noninvasive ventilation or an oxygen mask prior to induction. The primary outcome is the incidence of hypoxemia, defined as a peripheral oxygen saturation <85% between induction and 2 minutes after intubation. The secondary outcome is the lowest oxygen saturation between induction and 2 minutes after intubation. Enrollment began on 10 March 2022 and is expected to conclude in 2023.InterpretationThe PREOXI trial will provide important data on the effectiveness of noninvasive ventilation and oxygen mask preoxygenation for the prevention of hypoxemia during emergency tracheal intubation. Specifying the protocol and statistical analysis plan prior to the conclusion of enrollment increases the rigor, reproducibility, and interpretability of the trial.Clinical trial registration numberNCT05267652HIGHLIGHTS• Hypoxemia is common during emergency tracheal intubation• Supplemental oxygen prior to intubation (preoxygenation) reduces risk of hypoxemia• The PREOXI trial compares noninvasive ventilation vs oxygen mask preoxygenation• This protocol describes the design, methods, and planned analyses• PREOXI is the largest trial of preoxygenation for emergency intubation to date