Beyond pre-oxygenation: Contemporary strategies for prevention of peri-intubation hypoxia in anesthesia and critical care

Peri-intubation hypoxia remains a major cause of airway-related morbidity and mortality during anesthesia and critical care airway management. Critically ill patients, obese individuals, pregnant women, and patients with limited physiological reserve are especially vulnerable to rapid oxygen desaturation during the induction of anesthesia and tracheal intubation. Contemporary airway management increasingly focuses on optimization of oxygenation throughout the peri-intubation period rather than conventional pre-oxygenation alone. Current strategies include head-up positioning, non-invasive ventilation, high-flow nasal oxygen, apneic oxygenation, delayed sequence intubation, and peri-intubation physiological optimization. Emerging evidence supports multimodal oxygenation strategies to prolong safe apnea time and reduce severe desaturation events. This review summarizes the pathophysiology of peri-intubation hypoxia, critically evaluates current preventive strategies, and discusses future directions in peri-intubation oxygenation practices.