Pre-oxygenation using high flow humidified nasal oxygen or face mask oxygen in pregnant people – a prospective randomised controlled crossover non-inferiority study (The HINOP2 study)

Abstract

Background

Airway guidelines recommend pre-oxygenation of obstetric patients to an end tidal oxygen concentration (etO₂) ≥90%. High flow nasal oxygen (HFNO) achieves this in 60% of pregnant people. However face mask (FM) pre-oxygenation also may not achieve this target in all patients. In this study we determined whether HFNO pre-oxygenation is non-inferior to FM pre-oxygenation.

Methods

This randomised controlled crossover non-inferiority trial was conducted on healthy participants of gestational age ≥37 weeks in a simulated environment. Participants underwent pre-oxygenation for three minutes with HFNO and FM oxygen in randomised order. HFNO was delivered at a maximal flow of 70 l.min^-1 and FM oxygen at 10 l.min^-1. The primary outcome was etO₂ on first expired breath after pre-oxygenation. Non-inferiority was defined as a mean difference in first etO₂ between groups of ≤5%.

Results

Seventy participants were randomised with 62 analysed. Age (mean (SD)), gestation (median (IQR)), and body mass index (median (IQR)), were 34.7 (4.6) years, 39 (38.4, 39.4) weeks, 29 (26.6, 32.4) kg.m^-2 respectively. First etO₂ after HFNO pre-oxygenation was greater than after FM pre-oxygenation (HFNO pre-oxygenation mean (SD) 90.2 (3.9)% versus FM pre-oxygenation 88.7 (3.0)%; mean difference = 1.45%, 95% CI 0.19 to 2.72%; p = 0.025. Forty-four (71%) participants achieved ≥90% first etO₂ concentration after HFNO pre-oxygenation versus 27 (44%) after FM pre-oxygenation (p = 0.002).

Conclusions

In this cohort of pregnant people at term in a simulated environment, pre-oxygenation with HFNO was not inferior to FM pre-oxygenation. FM pre-oxygenation did not achieve pre-oxygenation targets in over 50% of participants.