How to improve preoxygenation before intubation in patients at risk

Airway management is one of the most commonly performed procedures in operating rooms (OR), intensive care units (ICUs), and emergency departments (EDs). Hypoxemia and cardiovascular collapse represent the initial and most serious life-threatening complications associated with difficult airway access, both in planned intubations (e.g., scheduled surgery) and in emergency intubations of critically ill patients [1–3]. To prevent and limit the incidence of hypoxemia following intubation, several pre-oxygenation techniques have been proposed. Nonetheless, these techniques, which usually combine breathing maneuvers and high inspired oxygen fraction (FiO2), may be associated with adverse effects and may be complicated by post-intubation atelectasis [4]. They may also provoke discomfort for patients and are time consuming in daily practice. The objectives of the present review are to describe the rationale for optimizing pre-oxygenation and associated maneuvers, to discuss the evidence for performing these maneuvers, and finally to propose an algorithm for secure airway management in patients considered ‘at risk’ of life-threatening complications.