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TOPLINE:

Preoxygenation with a bag-valve-mask device did not reduce the risk for hypoxemia compared with preoxygenation with a facemask during emergency tracheal intubation in the emergency department (ED) or ICU.

METHODOLOGY:

• Researchers conducted a post hoc secondary analysis involving 1156 patients (median age, 57 years) enrolled in two randomized trials, PREOXI and DEVICE, across nine EDs and 23 ICUs in the US.
• Participants were categorized into two preoxygenation groups: 136 were preoxygenated using a bag-valve-mask device (without manual ventilation), and 1020 were preoxygenated using a non-rebreathing facemask (with or without a nasal cannula).
• The primary outcome was the incidence of hypoxemia, defined as peripheral oxygen saturation < 85% between induction of anesthesia and 2 minutes after tracheal intubation.
• The secondary outcome was the lowest oxygen saturation between induction of anesthesia and 2 minutes after tracheal intubation. Exploratory outcomes were ventilator-free days through day 28, length of stay in the ICU, and in-hospital mortality.

TAKEAWAY:

• Hypoxemia occurred in 14.7% of participants in the bag-valve-mask device group and 15% of participants in the facemask oxygen group, with no difference in the odds of hypoxemia between the groups (adjusted odds ratio [aOR], 1.22; 95% CI, 0.72-2.16).
• Both groups had similar median lowest oxygen saturation at anesthesia induction (98% vs 97%; adjusted mean difference, -0.25%).
• No significant differences were observed between the groups for ventilator-free days through day 28 (median, 21 vs 23 days; adjusted mean difference, -1.14 days), length of stay in the ICU (median, 6 vs 6 days; adjusted mean difference, 1.47 days), or in-hospital mortality (29.4% vs 27.1%; aOR, 1.53).

IN PRACTICE:

"Preoxygenation with a bag-valve-mask device did not reduce the risk of hypoxemia compared to preoxygenation with facemask oxygen in critically ill patients undergoing emergency tracheal intubation in the ED or ICU setting," the authors wrote.

SOURCE:

The study was led by Christopher D. Chou, MD, Wake Forest School of Medicine, Winston-Salem, North Carolina. It was published online on July 22, 2025, in the Annals of Emergency Medicine.

LIMITATIONS:

The lack of randomization may have introduced residual confounding despite propensity adjustment. Key preoxygenation details — including oxygen mask flow rates, which may have modified the fraction of inspired oxygen, and the use of a positive end-expiratory pressure valve, which may have affected lung oxygen content — were not recorded. The study was underpowered by the small bag-valve-mask cohort; therefore, modest differences between techniques may have been missed. Additionally, although hypoxemia during tracheal intubation was the primary outcome, it was not patient-centered.

DISCLOSURES:

The primary studies from which the data were derived were funded by the Defense Health Agency J9 Restoral program. The authors reported having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.