Study shows noninvasive ventilation decreases the risk of hypoxemia

The Ohio State University Wexner Medical Center is a member of the Pragmatic Critical Care Research Group, a network founded in 2013 to improve care for critically ill patients by using clinical trials to compare commonly used treatments. We’re one of 20 health systems across the country that conducts federally funded clinical trials in emergency and critical care medicine.

The Ohio State University College of Medicine’s Division of Pulmonary, Critical Care and Sleep Medicine recently participated in a multicenter, randomized trial conducted at 24 emergency departments and intensive care units in the United States in which 1,301 randomly assigned critically ill adults undergoing tracheal intubation received preoxygenation with either noninvasive ventilation or an oxygen mask. Researchers evaluated whether preoxygenation with noninvasive ventilation would be more effective in decreasing the risk of hypoxemia (low levels of oxygen in the blood) than preoxygenation with an oxygen mask. Of those 1,301, we saw around 70 of those patients here at Ohio State.

The study results were published in the June 13 issue of the New England Journal of Medicine. “Noninvasive Ventilation for Preoxygenation during Emergency Intubation” was co-authored by Ohio State Pulmonary, Critical Care and Sleep Medicine fellows Caleb Taylor, MD, MPH, and Patrick Kramer, MD.

The study revealed that preoxygenation with noninvasive ventilation, as compared with preoxygenation with an oxygen mask, lowered the risk of hypoxemia during tracheal intubation by approximately half.

The results surprised Matt Exline, MD, MPH, clinical professor of Internal Medicine in the Division of Pulmonary, Critical Care and Sleep Medicine in the Ohio State College of Medicine and the site principal investigator for the study.

“The standard of care in the ICU between intubation and the ventilator has historically been an oxygen mask. Intubation is a high-risk procedure, given that oxygen levels drop in the time before the vent is initiated. We’re always look for ways to prevent those levels from dropping.

“I thought this study would confirm our use of full oxygen. But it instead showed a significant reduction in poor outcomes for those noninvasive ventilation was used on,” he says.

Hypoxemia occurred less often in the noninvasive-ventilation group (9.1%) than in the oxygen-mask group (18.5%). The risk of aspiration was low in both groups (0.9% for noninvasive-ventilation and 1.4% for oxygen mask). In addition, the noninvasive-ventilation group had a lower incidence of cardiac arrest, an exploratory procedural outcome.

“Especially impressive is how few cardiac arrests there were in the study – only one patient in the noninvasive-ventilation group compared to seven in the oxygen-mask group,” Dr. Exline says.

Efforts are now underway to share this important procedural change widely. Dr. Exline thinks the medical center is in great shape to be a leader in this implementation.

“Participating in the study allowed us to get used to using noninvasive ventilation during our procedures. Our respiratory therapists are comfortable with it. It’s now up to us as clinical leaders to implement it widely.

“This is the kind of research that we at Ohio State can excel at. We have a giant hospital system. We have a group of providers – advanced practice providers, physicians, pharmacists – able to practice at the top of their license. This work was done by whole units of professionals coming together and asking really important questions,” he says.

There are more trials on the horizon that will look at basic ICU practices. Dr. Exline expects our hospital and our clinical experts to be willing students.

“Every person who comes through our doors helps us get smarter as to how we care for our patients.”