Pre- and apnoeic high-flow oxygenation for rapid sequence intubation in the emergency department (the Pre-AeRATE trial): A multicentre randomised controlled trial

Evidence regarding the efficacy of high-flow nasal cannula (HFNC) oxygenation forpreoxygenation and apnoeic oxygenation is conflicting. Our objective is to evaluate whether HFNCoxygenation for preoxygenation and apnoeic oxygenation maintains higher oxygen saturation (SpO2)during rapid sequence intubation (RSI) in ED patients compared to usual care.Methods: This was a multicentre, open-label, randomised controlled trial in adult ED patientsrequiring RSI. Patients were randomly assigned 1:1 to either intervention (HFNC oxygenation at60L/min) group or control (non-rebreather mask for preoxygenation and nasal prongs of at least 15L/min oxygen flow for apnoeic oxygenation) group. Primary outcome was lowest SpO2 during the firstintubation attempt. Secondary outcomes included incidence of SpO2 falling below 90% and safeapnoea time.Results: One hundred and ninety patients were included, with 97 in the intervention and 93 in thecontrol group. Median lowest SpO2 during the first intubation attempt was 100% in both groups. Incidenceof SpO2 falling below 90% was lower in the intervention group (15.5%) compared to the control group(22.6%) (adjusted relative risk=0.68, 95% confidence interval [CI] 0.37–1.25). Post hoc quantileregression analysis showed that the first quartile of lowest SpO2 during the first intubation attemptwas greater by 5.46% (95% CI 1.48–9.45%, P=0.007) in the intervention group.Conclusions: Use of HFNC for preoxygenation and apnoeic oxygenation, when compared to usualcare, did not improve lowest SpO2 during the first intubation attempt but may prolong safe apnoea time.Keywords: Airway management, apnoeic oxygenation, high-flow nasal oxygenation, preoxygenation,rapid sequence intubation