Angela Maria Piccolo

Tracheal intubation in patients at risk of acute hypoxemic respiratory failure (AHRF) carries a high risk of life-threatening desaturation, and the choice of peri-intubation oxygenation strategy critically influences patient safety. This narrative review synthesizes current evidence on non-invasive oxygenation techniques—high-flow nasal oxygen (HFNO), non-invasive ventilation (NIV), and their combination—across the pre-oxygenation, apneic, and awake-intubation phases of airway management. We examine the physiological mechanisms underlying each modality, appraise landmark randomized trials and meta-analyses (including PREOXI, OPTINIV, and OPTIMASK), and address disease-specific considerations in chronic obstructive pulmonary disease, heart failure, interstitial lung disease, severe obesity, obstructive sleep apnea, and obstetric, pediatric, and trauma populations. The evidence supports a phenotype-driven hierarchy rather than a single dominant technique: NIV—optionally combined with HFNO for apneic oxygenation—is preferred in severely hypoxemic critically ill patients, whereas HFNO alone is adequate for many moderately hypoxemic or non-hypoxemic patients. Progressive hypercapnia limits apneic oxygenation, particularly in chronic CO₂ retainers, underscoring the value of continuous CO₂ monitoring. Persistent under-implementation of NIV-based pre-oxygenation reveals a gap between evidence and practice. Individualized, physiology-guided oxygenation—aligned with the goals of personalized peri-procedural medicine—offers the greatest potential to reduce peri-intubation morbidity.

Tracheal intubation in patients at risk of acute hypoxemic respiratory failure (AHRF) carries a high risk of life-threatening desaturation, and the choice of peri-intubation oxygenation strategy critically influences patient safety. This narrative review synthesizes current evidence on non-invasive oxygenation techniques—high-flow nasal oxygen (HFNO), non-invasive ventilation (NIV), and their combination—across the pre-oxygenation, apneic, and awake-intubation phases of airway management. We examine the physiological mechanisms underlying each modality, appraise landmark randomized trials and meta-analyses (including PREOXI, OPTINIV, and OPTIMASK), and address disease-specific considerations in chronic obstructive pulmonary disease, heart failure, interstitial lung disease, severe obesity, obstructive sleep apnea, and obstetric, pediatric, and trauma populations. The evidence supports a phenotype-driven hierarchy rather than a single dominant technique: NIV—optionally combined with HFNO for apneic oxygenation—is preferred in severely hypoxemic critically ill patients, whereas HFNO alone is adequate for many moderately hypoxemic or non-hypoxemic patients. Progressive hypercapnia limits apneic oxygenation, particularly in chronic CO₂ retainers, underscoring the value of continuous CO₂ monitoring. Persistent under-implementation of NIV-based pre-oxygenation reveals a gap between evidence and practice. Individualized, physiology-guided oxygenation—aligned with the goals of personalized peri-procedural medicine—offers the greatest potential to reduce peri-intubation morbidity.

Background: Patients with chronic cardio-respiratory diseases face substantially elevated perioperative complication risks. High-flow nasal oxygen (HFNO) therapy has emerged as a promising non-invasive respiratory support modality, yet evidence specific to this high-risk population has not been comprehensively synthesized. Objectives: To systematically evaluate HFNO effectiveness across the perioperative continuum—including pre-oxygenation, apneic oxygenation, and post-extubation support—in patients with chronic obstructive pulmonary disease, heart failure, interstitial lung disease, obesity, and related conditions. We aimed to compare HFNO with alternative modalities and provide evidence-based implementation guidance. Methods: We conducted a comprehensive narrative review with systematic search of major databases including PubMed, Embase, and the Cochrane Library for randomized controlled trials, systematic reviews, and observational studies involving adult patients with chronic cardio-respiratory diseases undergoing surgery with HFNO intervention at any perioperative phase. Quality assessment using established tools was performed with structured narrative synthesis organized by perioperative phase and disease population. Results: The review synthesizes evidence across multiple perioperative applications, comparing HFNO effectiveness with conventional oxygen therapy and non-invasive ventilation. Disease-specific considerations for chronic obstructive pulmonary disease, heart failure, obesity and obstructive sleep apnea, interstitial lung disease, and thoracic surgery populations are delineated. Evidence-based clinical algorithms for patient selection, protocol optimization, and escalation strategies are provided. Cost-effectiveness, implementation barriers, training requirements, and integration into Enhanced Recovery pathways are addressed. Conclusions: HFNO represents a valuable non-pharmacological intervention for perioperative respiratory optimization in chronic cardio-respiratory disease patients. This comprehensive synthesis provides clinicians with evidence-based guidance for implementation while identifying critical research gaps. Proper patient selection and protocol optimization can reduce postoperative pulmonary complications, prevent reintubation, and improve outcomes in this high-risk population. Future research should focus on personalized approaches, long-term outcome assessment, and implementation science. Keywords: High-flow nasal oxygen; HFNO; perioperative care; chronic obstructive pulmonary disease; heart failure; respiratory failure; non-invasive respiratory support; surgical complications; perioxygenation.