Original Investigation
Emergency Medicine
May 20, 2025
Preoxygenation With and Without Positive End-Expiratory Pressure in Lung-Healthy Volunteers: A Randomized Clinical Trial
Giulia Roveri, Anna Camporesi, Alex Hofer, et al
JAMA Netw Open. 2025;8(5):e2511569. doi:10.1001/jamanetworkopen.2025.11569
Question Is there a difference in the efficacy of 3 preoxygenation devices for use in emergency medicine—nonrebreather mask (NRM), bag-valve mask (BVM), and BVM with positive end-expiratory pressure (BVM plus PEEP)—in lung-healthy volunteers?
Findings In this crossover randomized clinical trial of 53 volunteers, including adults with normal weight, adults with overweight or obesity, and children aged 6 to 12 years, BVM and BVM plus PEEP achieved higher expiratory oxygen concentration compared with NRM. BVM plus PEEP improved ventilation in dependent lung regions.
Meaning These findings suggest that adding PEEP to BVM may improve preoxygenation of patients undergoing emergency intubation.
Abstract
Importance Optimal preoxygenation is critical in emergency medicine to prevent desaturation during airway management, especially in high-risk populations. Identifying the most effective preoxygenation device across diverse patient groups remains a clinical priority.
Objective To compare the efficacy of 3 preoxygenation devices—nonrebreather mask (NRM), bag-valve mask (BVM), and BVM with positive end-expiratory pressure (BVM plus PEEP)—in lung-healthy volunteers.
Design, Setting, and Participants This crossover randomized clinical trial was conducted from May 26 to 31, 2024, at Eurac Research, Bolzano, Italy. Volunteer participants included lung-healthy adults with normal weight (NM), adults with overweight or obesity (OW-OB), and children aged 6 to 12 years.
Exposures Preoxygenation using each device (NRM, BVM, BVM plus PEEP) with 15 L/min of oxygen for a duration of 3 minutes in a randomized order.
Main Outcomes and Measures The primary outcome was expiratory oxygen concentration (Feo2) at the end of preoxygenation. Secondary outcomes included ventilation in dependent lung regions assessed using electrical impedance tomography, noninvasive continuous monitoring of oxygenation status (oxygenation reserve index [ORI]) at the end of preoxygenation, and the time taken for ORI to return to baseline values.
Results The study included 53 participants, 39 male (74%) and 14 female (26%), of whom 16 were adults with NW (mean [SD] age, 36 [11] years), 18 were adults with OW-OB (mean [SD] age, 45 [11] years), and 19 were children (mean [SD] age, 8 [3] years). Mean (SD) Feo2 at the end of preoxygenation was higher with BVM and BVM plus PEEP compared with NRM in adults with NW (72.1% [5.9%] and 75.6% [4.3%], respectively, vs 52.5% [6.1%]; P < .001), adults with OW-OB (65.8% [10.4%] and 73.0% [6.4%], respectively, vs 51.9% [6.1%]; P < .001), and children (64.6% [13.4%] and 67.5% [10.2%], respectively, vs 38.5% [7.5%]; P < .001). Ventilation in dependent lung regions was higher with BVM plus PEEP than NRM in adults with NW (BVM plus PEEP, 51.9 [9.3] vs NRM, 47.0 [5.7]; P = .03) and children (BVM plus PEEP, 53.0 [7.3] vs NRM, 47.7 [7.0]; P = .002). ORI at the end of preoxygenation was higher with BVM plus PEEP than with NRM in adults with OW-OB (BVM plus PEEP, 0.79 [0.13] vs NRM, 0.73 [0.13]; P < .001). Additionally, the mean (SE) time for ORI to return to baseline was longer with BVM plus PEEP compared with NRM in both adults with OW-OB (BVM plus PEEP, 196 [74] seconds vs NRM, 158 [53] seconds; P = .01) and children (BVM plus PEEP, 115 [59] seconds vs NRM, 62 [36] seconds; P < .001).
Conclusions and Relevance In this crossover randomized clinical trial, preoxygenation with PEEP was more effective than preoxygenation without PEEP, resulting in higher Feo2 values and improved ventilation in dependent lung regions. These findings suggest that BVM plus PEEP should be prioritized for preoxygenation in emergency settings.
Trial Registration ClinicalTrials.gov Identifier: NCT06370689
