Authors: Misiriyyah N et al.
Cureus 18(2): e104230, February 25, 2026
This case report describes the use of a dual-modality preoxygenation strategy—noninvasive ventilation (NIV) combined with high-flow nasal cannula (HFNC)—to mitigate peri-intubation hypoxemia in a patient with severe acute respiratory distress syndrome (ARDS).
A 46-year-old man with necrotizing pneumonia presented with profound hypoxemia (SpO₂ 80% on room air) and severe ARDS (PaO₂/FiO₂ ratio of 68). Despite maximal oxygenation via non-rebreather mask, his saturation remained < 90%, necessitating urgent rapid sequence intubation (RSI). Given the high risk for catastrophic desaturation during apnea, a physiologically driven dual-modality approach was implemented.
Preoxygenation was performed using BiPAP with PEEP of 8 cmH₂O for five minutes to recruit alveoli and improve functional residual capacity. Immediately before induction, HFNC at 60 L/min was initiated to maintain apneic oxygenation during laryngoscopy. After induction with etomidate and succinylcholine, NIV was removed but HFNC remained in place. The patient maintained SpO₂ > 94% during a 75-second apneic period without hemodynamic instability or need for vasopressors.
The physiologic rationale is compelling:
NIV provides positive end-expiratory pressure (PEEP), promoting alveolar recruitment, improving ventilation-perfusion matching, and increasing oxygen reservoir capacity. However, once the mask is removed for laryngoscopy, oxygen delivery ceases. HFNC bridges this “oxygenation gap” by delivering heated, humidified high-flow oxygen during apnea, facilitating dead-space washout and modest PEEP while allowing intubation access.
The authors cite prior trials (including work by Jaber and Frat) supporting synergistic benefit when NIV and HFNC are combined in severely hypoxemic patients, particularly in ARDS. Evidence suggests this approach reduces severe peri-intubation desaturation compared with either modality alone.
Limitations are typical of a single case report. No standardized protocol exists for optimal duration, timing, or flow parameters. EtO₂ monitoring was not obtained, and the findings cannot establish causality or generalizability.
For anesthesiologists and airway managers, this report reinforces several key principles:
• Severe ARDS drastically shortens safe apnea time.
• PEEP during preoxygenation is critical in shunt physiology.
• HFNC can meaningfully extend safe apnea by providing apneic oxygenation.
• Combining recruitment (NIV) and continuous oxygenation (HFNC) addresses complementary physiologic targets.
• A structured protocol may reduce peri-intubation hypoxemia in high-risk patients.
This dual-modality technique is particularly relevant to emergency intubations in ICU, ED, or even OR settings involving refractory hypoxemia.
Key Points
• Severe ARDS patients have minimal oxygen reserve and rapid desaturation risk during RSI.
• NIV improves recruitment and PEEP before induction.
• HFNC maintains oxygenation during apnea and provides dead-space washout.
• Dual-modality preoxygenation maintained SpO₂ > 94% during a 75-second apnea in severe ARDS.
• Larger randomized trials are needed to standardize protocols and confirm efficacy.
Thank you to Cureus for allowing us to summarize and discuss this article.