A Nasal Cannula Under the Noninvasive Positive Pressure Ventilation Mask?

Daniel J. Pallin, MD, MPH


A crossover trial in healthy volunteers suggests that a nasal cannula does not increase mask leaking significantly.


Research suggests that apneic oxygenation is of benefit during rapid sequence intubation (NEJM JW Emerg Med Sep 2017 and Am J Emerg Med 2017; 35:1184). Apneic oxygenation involves use of highflow oxygen via a nasal cannula during laryngoscopy. In practice, it means that patients who may require intubation are given a nasal cannula and a non-rebreather mask or noninvasive positive pressure ventilation (NPPV).


To evaluate whether a nasal cannula causes the NPPV mask to leak, investigators enrolled 64 healthy volunteers in a crossover study in which each participant served as his or her own control. Participants underwent 1 minute of NPPV with a nasal cannula and 1 minute of NPPV without a nasal cannula, in random order, with a 2-minute washout period between interventions. The main outcome measure was the amount of gas leaked from the mask during 1 minute, with a prespecified noninferiority margin of 5 L/minute. There was no significant increase in mask leakage when the nasal cannula was used.


This provocative small study suggests that for patients with serious respiratory compromise
who require NPPV, a nasal cannula should be placed beneath the NPPV mask so that it is ready in case NPPV needs to be converted to rapid sequence intubation.


Brown DJ et al. Face mask leak with nasal cannula during noninvasive positive pressure ventilation: A randomized crossover trial. Am J Emerg Med 2017 Dec 2; [e-pub].



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