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NIPPV emerged as the most effective preoxygenation method to reduce hypoxemia during intubation, offering valuable guidance for critical care practice.

A study published in the June 2025 issue of Lancet Respiratory Medicine emphasized the critical role of preoxygenation before intubation and explored the uncertain comparative effectiveness of strategies such as facemask oxygen, high-flow nasal cannula (HFNC), and non-invasive positive pressure ventilation (NIPPV).   

Researchers compared the efficacy and safety of HFNC, NIPPV, and facemask oxygen for preoxygenation in individuals who were critically ill and required tracheal intubation.  

They searched Embase, MEDLINE, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials for randomized clinical trials (RCTs) published from database inception to Oct 31, 2024. Eligible studies included RCTs comparing HFNC vs NIPPV, HFNC vs facemask oxygen, or NIPPV vs facemask oxygen in adults (age ≥18 years) who were critically ill and required intubation in intensive care or emergency department settings. No additional criteria were applied for network meta-analysis inclusion.  

Covidence software was used to screen studies, 2 reviewers independently screened titles and abstracts, followed by full-text articles. Disagreements were resolved through discussion or by a third-party adjudicator. Summary-level data were manually extracted using a structured data collection form. Outcomes assessed included hypoxemia during intubation, first-attempt during intubation success, serious adverse events (AEs), and all-cause mortality. A frequent random-effects network meta-analysis was performed. Risk of bias was evaluated using the modified Cochrane tool (RoB 2.0), and certainty of evidence was rated using the GRADE approach. The study protocol was registered on the Open Science Framework.  

The results showed that 6,900 records were initially identified, with 48 articles screened in full and 15 studies involving 3,420 individuals. Use of NIPPV for preoxygenation probably reduced hypoxemia during intubation compared with a HFNC (relative risk 0·73 [95% CI 0·55–0·98]; P=0·032; moderate certainty) and facemask oxygen (0·51 [0·39–0·65]; P<0·0001; high certainty), HFNC lowered the incidence of hypoxemia compared to facemask oxygen (0·69 [0·54–0·88]; P=0·0064; high certainty). All preoxygenation approaches showed no impact on first-attempt intubation success (all low certainty). No strategy appeared to influence all-cause mortality (very low-to-moderate certainty). The NIPPV probably decreased the risk of serious AEs vs facemask oxygen (0·30 [0·12–0·77]; P=0·011; moderate certainty) and might have reduced risk compared to HFNC (0·32 [0·11–0·91]; P=0·035; low certainty). A HFNC likely did not reduce the risk of serious AEs vs facemask oxygen (0·95 [0·60–1·51]; P=0·83; low certainty).  

Investigators concluded that preoxygenation with NIPPV or HFNC, rather than facemask oxygen, likely reduced hypoxemia during tracheal intubation in adults with critical illness. 

Source: thelancet.com/journals/lanres/article/PIIS2213-2600(25)00029-3/abstract