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

Introduction: Evidence regarding the efficacy of high-flow nasal cannula (HFNC) oxygenation for preoxygenation and apnoeic oxygenation is conflicting. Our objective is to evaluate whether HFNC oxygenation for preoxygenation and apnoeic oxygenation maintains higher oxygen saturation (SpO(2)) 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 patients requiring RSI. Patients were randomly assigned 1:1 to either intervention (HFNC oxygenation at 60L/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 SpO(2) during the first intubation attempt. Secondary outcomes included incidence of SpO(2) falling below 90% and safe apnoea time. Results: One hundred and ninety patients were included, with 97 in the intervention and 93 in the control group. Median lowest SpO(2) during the first intubation attempt was 100% in both groups. Incidence of SpO(2) 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 quantile regression analysis showed that the first quartile of lowest SpO(2) during the first intubation attempt was 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 usual care, did not improve lowest SpO(2) during the first intubation attempt but may prolong safe apnoea time.

Automated summary

This study evaluated the efficacy of HFNC oxygenation for maintaining higher SpO(2) during RSI in emergency department patients. The results showed that HFNC oxygenation did not improve the lowest SpO(2) during the first intubation attempt compared to usual care, but it may prolong safe apnoea time.