Bradley King

WRIT 4310
Literature Review
Best Method to Reduce Hypoxemia During Endotracheal Intubation
Acute respiratory failure is a fatal condition that frequently requires mechanical
ventilation following endotracheal intubation. Critically ill patients are subject to severe
complications during the procedure with hypoxemia being the most commonly reported
procedural complication (De Jong, et al., 2013). This report examines preoxygenation and periintubation practices and attempts to determine which methodology is a superior at reducing
oxyhemoglobin desaturation prior to endotracheal intubation.
Mechanisms of Hypoxemia
Oxygenation is a term used to describe the manner of oxygen passively diffusing from
the alveolus to the pulmonary capillary, where it then binds to hemoglobin in red blood cells or
dissolves in plasma. Many techniques are available to detect if oxygenation is reduced or
inadequately meting the metabolic demands of the systemic tissues; but the arterial oxygen
saturation (SaO2) and the arterial oxygen tension (PaO2) are primarily utilized determine the
presence of hypoxemia.
Hypoxemia is defined as a decrease in the partial pressure of oxygen in the arterial blood.
It exists when the PaO2 is less than 60 mmHg or when the measured SpO2 falls below 90%.
Low oxygen levels can be caused by number of different factors which adversely affect every
tissue in the body. These factors include hypoventilation, ventilation-perfusion mismatch,
physiologic shunt, diffusion limitations, or decreased inspired oxygen tension (Glenny, 2008).
When a patients oxygen saturation is below 90%, their location on the steep portion of the
oxyhemoglobin dissociation curve can fall to dangerous levels (<70%) within moments (West,
2013). When oxygen saturation falls below 70%, it puts patients at risk for dysrhythmia,
hemodynamic decompensation, hypoxic brain injury, and death (Weingart & Richard, 2012). In

Bradley King
WRIT 4310
Literature Review
order to reduce this manifestation, clinicians administer supplemental oxygen to increase the
concentration gradient in the alveoli, subsequently increasing the PaO2 and SaO2. Thus,
increasing the the amount of oxygen in the patients blood and lungs extends the period of safe
apnea during paralysis lowers the risk of complications during the intubation procedure. This
practice is commonly referred to as pre-oxygenation.
Standard Preoxygenation Practice
The goal of the pre-oxygenation is to denitrogenate the residual capacity of the lung and
maximally oxygenate the bloodstream to achieve a SpO2 of 94-100%. This can be accomplished
by administering oxygen through a non-rebreather mask (NRB) applied directly applied to the
patients face. This method is the most common form of preoxygenation and produces a fraction
of inspired oxygen of 60-80% when set at 15 lpm (Weingart, 2010). In the upright position,
patients are instructed to take eight vital capacity breaths or 3 minutes worth of normal tidal
volume breathing to achieve a hyperoxic state (SpO2 = 100%) (Pandit, Thomas, & Robbins,
2003). In healthy patients, this technique adequately oxygenates the patient for as long as 8
minutes without saturations dropping below the 90% threshold when apneic. However, in ill
patient with diseased lungs or abnormal body habitus, this may be significantly reduced
(Weingart, 2010). Therefore, additional therapy may be warranted to combat the hypoxemia,
such as a high-flow nasal cannula.
A high-flow nasal cannula can be applied beneath the existing NRB in order to permit
apneic oxygenation. The accompanying device set a 15 lpm has its absolute advantages: it can
remain in place throughout the entire procedure and provide continuous oxygen, whereas the
NRB mask has to be removed prior to intubation. The literature also suggests that the incidence
of oxygen desaturation decreases during rapid sequence intubation when a high flow nasal

Bradley King
WRIT 4310
Literature Review
cannula is applied (Wimalasena, Burns, Reid, Ware, & Habig, 2014). Lastly, oxygen insufflation
via nasal cannula is associated with significant increases and duration of oxygen saturation
during intubation in the obese population (Ramachandran, Cosnowski, Shanks, & Turner, 2010).
Therefore, high flow nasal insufflation in conjunction with standard preoxygenation practice may
be an effective method to prevent oxygen desaturation during intubation. Yet, patients who are
unable to achieve oxygen saturation above 93% despite standard preoxygenation are still at risk
for desaturation during intubation. Consequently, a more aggressive approach is warranted in this
population.
Advanced Preoxygenation Practice
When patients are unable to achieve an oxygen saturation above 93% following standard
preoxygenation, the probability of them desaturating during intubation increases significantly.
When this occurs, the patient is likely exhibiting shut physiology that is refractory to oxygen
therapy (Jaber, et al., 2009). Physiologic shunt occurs when areas of lung alveoli are not properly
ventilated, but still have intact blood vessels surrounding them. This perfusion without
ventilation leads to a direct mixing of deoxygenated venous blood into the arterial blood,
resulting in hypoxemia. The most frequently reported causes of shunt include pneumonia,
atelectasis, pulmonary edema, and acute respiratory distress syndrome (Weingart, 2010). No
matter how much oxygen is administered to a patient with shunt physiology, oxygenation will
never improve since the inhaled gas never reaches the blood. Therefore, the only way to correct
this issue is to fix the physiologic shunt. This can be accomplished with the application of
positive end expiratory pressure (PEEP) and increasing the functional residual capacity (FRC) of
the lung.

Bradley King
WRIT 4310
Literature Review
PEEP is defined as the alveolar pressure above atmospheric pressure that exists inside of
the lung at the end of expiration. Every individual has about 3-5 cmH2O of PEEP in their lungs
at all times, which is commonly referred to as the FRC. The FRC is determined by the
compliance of the lung tissue and the chest wall. These two equal opposing forces balance each
other out, keeping the alveoli inflated - similar to the windbag of a bagpipe (Selvi, Rao, &
Malathi, 2013). This volume acts as an air reservoir for physiologic use, which is particularly
important during intubation since the patient is completely relaxed and apneic. Therefore, if
PEEP and FRC are maximized prior to intubation, the oxygen reservoir subsequently increases
and acts as an oxygen storage tank, allowing oxygen to passively diffuse from the alveoli into the
pulmonary capillaries. This will in turn reduce physiologic shunt and improve oxygenation by
increasing the alveoli surface area.
The most widely utilized device used to increase FRC in the presence of hypoxic
respiratory failure is termed bi-level positive airway pressure (BIPAP). BIPAP delivers both
positive inspiratory airway pressure (IPAP) and expiratory positive airway pressure (EPAP), also
know as PEEP. The easiest way to think about BIPAP is to imagine blowing up a balloon. The
greater pressure applied inside of the balloon, the bigger the balloon becomes. Likewise, the
more pressure applied to the lungs, the greater the volume in the lung with a greater surface area
for oxygen to passively diffuse into the bloodstream.
In regards to the application of BIPAP, literature suggests that patients who exhibit signs
of shunt physiology should undergo the administration of BIPAP therapy as soon as possible to
prevent the hazards associated with hypoxemia (Vital, Ladeira, & N, 2013). In a study
conducted by Baillard et al., they examined the effect of BIPAP on critically ill patients with

Bradley King
WRIT 4310
Literature Review
hypoxemia who required intubation in the ICU. At the end of the preoxygenation period, patients
receiving preoxygenation via BIPAP had a mean SpO2 reading of 98%, whereas those receiving
standard preoxygenation therapy had a mean SpO2 reading of 93%. Of the patients in the BIPAP
group, 6 of 26 patients were unable to improve their low saturations with high FiO2 until they
received positive pressure (Baillard, et al., 2006). Therefore, the application of BIPAP is superior
in terms of oxygenation compared to standard preoxygenation practice.
Study

Patients

Intervention

Outcome

Baillard et al.

N= 53 administered
standard or advanced
preoxygenation
practice.

N= 26 received
standard
preoxygenation.

BIPAP applied 3 min

before intubation
ensured better SpO2
and PaO2values
compared to usual
preoxygenation
practice. Standard
preoxygenation failed
to improve SpO2 in
all the patients.

N= 26 hypoxemic
ICU patients
diagnosed with
pneumonia requiring
bronchoscopy

N= 13 received
standard oxygenation
via venture mask

(Antonell, et al., 2002)

N=27 received
advanced
preoxygenation.

In patients with
severe hypoxemia,
BIPAP is superior to
conventional oxygen
N= 13 received
supplementation in
BIPAP therapy
preventing
hypoxemia during
bronchoscopy
Table 1. Evidence supporting BIPAP as the superior preoxygenation technique
Conclusion
(Arcos, 2011)Hypoxemia is the most commonly observed complication during
endotracheal intubation and can be triggered by a number of physiological abnormalities, such as
pneumonia, atelectasis, pulmonary edema, or acute respiratory distress syndrome. In order to
counteract hypoxemia, clinicians administer high concentrations of supplemental oxygen prior to

Bradley King
WRIT 4310
Literature Review
intubation, increasing the PaO2 and SaO2. This increase permits a safety buffer for a definitive
airway to be placed.
This article examined two preoxygenation approaches respectively. They are classified as
standard or advanced preoxygenation practices. Following a review of the literature, I conclude
the following: patients who demonstrate a SpO2 measurement 94% with standard
preoxygenation are at a lower risk of desaturation during intubation. Therefore, clinicians may
proceed with endotracheal intubation.
On the other hand, patients who demonstrate a SpO2 measurements 93% with standard
preoxygenation are expected to be at high risk for desaturation. Therefore, advanced
preoxygenation practice or BIPAP therapy should be employed. Once the patient is
preoxygenation with the BIPAP and saturation >94% is achieved, intubation may proceed.

Bradley King
WRIT 4310
Literature Review

Bibliography
Antonell, M., Conti, G., Rocco, M., Arcangeli, A., Cavaliere, F., Proietti, R., &
Meduri, G. U. (2002). Noninvasive Positive-Pressure Ventilation vs
Conventional Oxygen Supplementation in Hypoxemic Patients
Undergoing Diagnostic Bronchoscopy. Chest, 121(4), 1149-1153.
Baillard, C., Fosse, J.-P., Sebbane, M., Chanques, G., Vincent, F., Courouble,
P., . . . Jabe, S. (2006). Noninvasive Ventilation Improves
Preoxygenation before Intubation of Hypoxic Patients . AMERICAN
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De Jong, A., Molinar, N., Terzi, N., Mongardon, N., Arnal, J.-M., Guitton, C., . . .
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Difficult Intubation in the Intensive Care Unit. American Journal of
Respiratory and Critical Care Medicine, 187(8), 832-839.
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Pandit, J. J., Thomas, D., & Robbins, P. A. (2003, November). Total Oxygen
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Ramachandran, S. K., Cosnowski, A., Shanks, A., & Turner, C. R. (2010, May).
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Randomized, Controlled Trial of Nasal Oxygen Administration . Journal
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Selvi, C. E., Rao, K. K., & Malathi. (2013) Should the Functional Residual
Capacity be Ignored? Journal of Clinical and Diagnostic Research, 7(1),
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Bradley King
WRIT 4310
Literature Review
West, J. B. (2013). Pulmonary Pathophysiology: The Essentials (Vol. 8).
Philadelphia, PA, USA: Lippincott Williams & Wilkins.
Wimalasena, Y., Burns, B., Reid, C., Ware, S., & Habig, K. (2014, December
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Rates During Rapid Sequence Intubation by an Australian Helicopter
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371-376.