BACKGROUND: Bronchial thermoplasty (BT) is a treatment for patients with poorly controlled, severe asthma. However, predictors of treatment response to BT are de fi ned poorly. RESEARCH QUESTION: Do baseline radiographic and clinical characteristics exist that predict response to BT? STUDY DESIGN AND METHODS: We conducted a longitudinal prospective cohort study of participants with severe asthma receiving BT across eight academic medical centers. Participants received three separate BT treatments and were monitored at 3 -month intervals for 1 year after BT. Similar to prior studies, a positive response to BT was de fi ned as either improvement in Asthma Control Test results of >= 3 or Asthma Quality of Life Questionnaire of >= 0.5. Regression analyses were used to evaluate the association between pretreatment clinical and quantitative CT scan measures with subsequent BT response. RESULTS: From 2006 through 2017, 88 participants received BT, with 70 participants (79.5%) identi fi ed as responders by Asthma Control Test or Asthma Quality of Life Questionnaire criteria. Responders were less likely to undergo an asthma -related ICU admission in the prior year (3% vs 25%; P = .01). On baseline quantitative CT imaging, BT responders showed less air trapping percentage (OR, 0.90; 95% CI, 0.82-0.99; P = .03), a greater Jacobian determinant (OR, 1.49; 95% CI, 1.05-2.11), greater SD of the Jacobian determinant (OR, 1.84; 95% CI, 1.04-3.26), and greater anisotropic deformation index (OR, 3.06; 95% CI, 1.06-8.86). INTERPRETATION: To our knowledge, this is the largest study to evaluate baseline quantitative CT imaging and clinical characteristics associated with BT response. Our results show that preservation of normal lung expansion, indicated by less air trapping, a greater magnitude of isotropic expansion, and greater within -lung spatial variation on quantitative CT imaging, were predictors of future BT response. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01185275; URL: www.clinicaltrials.gov

SESSION TITLE: Critical Care Posters 18 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm PURPOSE: Dexmedetomidine (DEX) is a central acting alpha2-adrenergic agonist indicated for the sedation of mechanically ventilated patients. DEX has analgesic, anxiolytic, and sedative properties. Since the mechanism of action is in the locus coeruleus, not the cerebral cortex, there is less risk for over-sedation and respiratory depression. DEX is associated with less delirium than benzodiazepines in clinical trials and has efficacy as an adjunct treatment for severe alcohol withdrawal and in agitated toxicology patients. Although off-label DEX use in non-intubated patients is widespread, there is a paucity of data regarding safety of DEX in these patients. Accordingly, the goal of this study was to evaluate the safety profile of DEX in non-intubated patients admitted to the ICU. Our secondary goal was to generally describe DEX usage (dosage, duration, indication) in the non-intubated ICU patient. METHODS: A multicenter retrospective chart review was conducted on patients who received DEX while hospitalized at five Omaha (Nebraska) metropolitan CHI Health hospital between 1/1/17 and 9/1/20. The study was approved by the Institutional Review Board. Inclusion criteria included age ≥19 years, use of DEX in an ICU for ≥24 hours, and no intubation at the time of DEX initiation. Exclusion criteria included age <19 years, use of DEX for <24 hours, or intubation at the time of DEX initiation. Our primary outcome was any documented adverse effects (AE) associated with DEX infusion. Data were analyzed using SPSS ver 28 (IBM, Inc). Mean ± SD or percentages were reported. RESULTS: Of 1,186 patients receiving DEX, 85 patients met inclusion and exclusion criteria. The cohort was 62.4% male with a mean age of 61.9 years and an average BMI of 27.9. Indications for DEX included respiratory failure (n=44), alcohol abuse (n=25), and agitation/delirium (n=16). Mean duration of DEX use was 60.8±44.3 hours (range 24-217). The DEX infusion dosage range was 0.1-1.5 mcg/kg/hr, with a mean minimal dosage of 0.21±0.06 and maximal dosage of 1.14±0.41. In the cohort, 41 of the patients (48.2%) required non-invasive ventilatory (NIV) support. There were 5 patients (5.9%) requiring intubation after being on DEX for >24 hours: 3 progressive respiratory failure, 1 alcohol withdrawal, and 1 multisystem organ failure due to alcoholic hepatitis. Non-respiratory AEs included bradycardia (n=8, 9.4%) and mild/transient hypotension (n=7, 8.2%). CONCLUSIONS: DEX was safe and effective when used in non-intubated ICU patients. The AE rate in this cohort was comparable to what is described with DEX among intubated patients. The need for intubation was low at ~5% and was attributable to the underlying disease process. CLINICAL IMPLICATIONS: This retrospective descriptive study suggests that DEX can safely be used for prolonged periods (> 24 hours) in non-intubated patients when properly monitored in an ICU. DISCLOSURES: No relevant relationships by Ara Choi No relevant relationships by Jacqueline Chung No relevant relationships by Chris Destache No relevant relationships by Megan Dethlefsen No relevant relationships by Adam Highley No relevant relationships by Erin Kajihiro No relevant relationships by Mark Malesker No relevant relationships by Lee Morrow No relevant relationships by Stephen Toth No relevant relationships by Zachariah Wittenberg

SESSION TITLE: Critical Care Posters 16 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm PURPOSE: Quetiapine (Seroquel) is FDA approved for the treatment of bipolar disorder, major depressive disorder, and schizophrenia. A common off label use is treatment of intensive care unit (ICU) delirium or agitation. Pilot data from our institution demonstrated quetiapine is not consistently discontinued once delirium has been resolved or upon transfer from the ICU. The goal of this study was to retrospectively evaluate the discontinuation rate of quetiapine in patients requiring ICU care and to delineate factors correlated with inappropriate continuation of quetiapine. METHODS: This study was approved by the Institutional Review Board. A retrospective chart review was conducted of patients receiving quetiapine for more than 24 hours while requiring ICU care between 6/1/2017 to 12/31/2021. Patients less than 19 years, taking quetiapine prior to admission, undergoing active alcohol withdrawal, having history of neurocognitive disorder, and receiving a continuous paralytic agent were excluded. The primary outcome was to evaluate the discontinuation of quetiapine at ICU and hospital discharge. Secondary outcomes included quetiapine administration (dosage, length of use, safety), variables that predict inappropriate continuation of therapy (ordering service, dose used), and discharge disposition. Statistical analysis was performed with SPSS. Mean (± SD) or percentages are reported. RESULTS: 216 patients met inclusion criteria (131 (61%) males and 85 (39%) females). Mean (± SD) age and weight were 62.5 ± 18.3 years and 88.2 ± 29.4 kg. Majority of quetiapine patients were white (87%) with 9% African American and 3% Hispanic. The frequency of quetiapine discontinuation was higher among patients being discharged from hospital compared to ICU downgrade (53.5% vs 19%, p < 0.001). At time of hospital discharge, patients were significantly more likely to go home if quetiapine was discontinued (19.4% vs.10%, p < 0.001). Patients with quetiapine discontinued at time of hospital discharge received significantly more baseline EKG monitoring (36% vs. 17.5%, p=0.003). CONCLUSIONS: 81% of patients started on quetiapine in the ICU continued to receive this therapy at the time of transfer out of the ICU: 27.5% of patients continued to receive quetiapine at the time of discharge. The hospital discharge rate was nearly twice as high for patients whose quetiapine was discontinued during the hospitalization. CLINICAL IMPLICATIONS: ICU clinicians need to be attentive to appropriate discontinuation of quetiapine; and 2) ongoing quetiapine prescription is associated with a lower rate of discharge to home. DISCLOSURES: No relevant relationships by Jacqueline Chung No relevant relationships by Chris Destache No relevant relationships by Mark Malesker No relevant relationships by Lee Morrow No relevant relationships by Robert Plambeck No relevant relationships by Srishti Singal

Background Systemic sclerosis (SSc) is a rare, complex, connective tissue disorder. Interstitial lung disease (ILD) is common in SSc, occurring in 35–52% of patients and accounting for 20–40% of mortality. Evolution of therapeutic options has resulted in a lack of consensus on how to manage this condition. This Delphi study was initiated to develop consensus recommendations based on expert physician insights regarding screening, progression, treatment criteria, monitoring of response, and the role of recent therapeutic advances with antifibrotics and immunosuppressants in patients with SSc-ILD. Methods A modified Delphi process was completed by pulmonologists (n = 13) and rheumatologists (n = 12) with expertise in the management of patients with SSc-ILD. Panelists rated their agreement with each statement on a Likert scale from − 5 (complete disagreement) to + 5 (complete agreement). Consensus was predefined as a mean Likert scale score of ≤ − 2.5 or ≥ + 2.5 with a standard deviation not crossing zero. Results Panelists recommended that all patients with SSc be screened for ILD by chest auscultation, spirometry with diffusing capacity of the lungs for carbon monoxide, high-resolution computed tomography (HRCT), and/or autoantibody testing. Treatment decisions were influenced by baseline and changes in pulmonary function tests, extent of ILD on HRCT, duration and degree of dyspnea, presence of pulmonary hypertension, and potential contribution of reflux. Treatment success was defined as stabilization or improvement of signs or symptoms of ILD and functional status. Mycophenolate mofetil was identified as the initial treatment of choice. Experts considered nintedanib a therapeutic option in patients with progressive fibrotic ILD despite immunosuppressive therapy or patients contraindicated/unable to tolerate immunotherapy. Concomitant use of nintedanib with MMF/cyclophosphamide can be considered in patients with advanced disease at initial presentation, aggressive ILD, or significant disease progression. Although limited consensus was achieved on the use of tocilizumab, the experts considered it a therapeutic option for patients with early SSc and ILD with elevated acute-phase reactants. Conclusions This modified Delphi study generated consensus recommendations for management of patients with SSc-ILD in a real-world setting. Findings from this study provide a management algorithm that will be helpful for treating patients with SSc-ILD and addresses a significant unmet need.

Although multiple risk factors for development of pneumonia in patients with trauma sustained in a motor vehicle accident have been studied, the effect of prehospital time on pneumonia incidence post-trauma is unknown.Is prolonged prehospital time an independent risk factor for pneumonia?We retrospectively analyzed prospectively collected clinical data from 806,012 motor vehicle accident trauma incidents from the roughly 750 trauma hospitals contributing data to the National Trauma Data Bank between 2010 and 2016.Prehospital time was independently associated with development of pneumonia post-motor vehicle trauma (P < .001). This association was primarily driven by patients with low Glasgow Coma Scale scores. Post-trauma pneumonia was uncommon (1.5% incidence) but was associated with a significant increase in mortality (P < .001, 4.3% mortality without pneumonia vs 12.1% mortality with pneumonia). Other pneumonia risk factors included age, sex, race, primary payor, trauma center teaching status, bed size, geographic region, intoxication, comorbid lung disease, steroid use, lower Glasgow Coma Scale score, higher Injury Severity Scale score, blood product transfusion, chest trauma, and respiratory burns.Increased prehospital time is an independent risk factor for development of pneumonia and increased mortality in patients with trauma caused by a motor vehicle accident. Although prehospital time is often not modifiable, its recognition as a pneumonia risk factor is important, because prolonged prehospital time may need to be considered in subsequent decision-making.

Controlled donation after circulatory death (DCD) has the potential to substantially increase the number of lung transplants thus offsetting some of the imbalance between need and organ availability. We examine the potential benefits associated with increased DCD utilization as well as the perceived barriers to the expansion of DCD. Solutions are offered as a means to expand DCD utilization across centers and nations.

BACKGROUND: The evolution of compliance and driving pressure in ARDS and the effects of time spent on noninvasive respiratory support prior to intubation have not been well studied. We conducted this study to assess the effect of the duration of noninvasive respiratory support prior to intubation (ie, noninvasive ventilation [NIV], high-flow nasal cannula [HFNC], or a combination of NIV and HFNC) on static compliance and driving pressure and retrospectively describe its trajectory over time for COVID-19 and non–COVID-19 ARDS while on mechanical ventilation. METHODS: This is a retrospective analysis of prospectively collected data from one university-affiliated academic medical center, one rural magnet hospital, and 3 suburban community facilities. A total of 589 subjects were included: 55 COVID-19 positive, 137 culture positive, and 397 culture-negative subjects. Static compliance and driving pressure were calculated at each 8-h subject-ventilator assessment. RESULTS: Days of pre-intubation noninvasive respiratory support were associated with worse compliance and driving pressure but did not moderate any trajectory. COVID-19–positive subjects showed non-statistically significant worsening compliance by 0.08 units per subject-ventilator assessment (P = .24), whereas COVID-19–negative subjects who were either culture positive or negative showed statistically significant improvement (0.12 and 0.18, respectively; both P < .05); a statistically similar but inverse pattern was observed for driving pressure. CONCLUSIONS: In contrast to non–COVID-19 ARDS, COVID-19 ARDS was associated with a more ominous trajectory with no improvement in static compliance or driving pressures. Though there was no association between days of pre-intubation noninvasive respiratory support and mortality, its use was associated with worse overall compliance and driving pressure.

BACKGROUND: Although multiple risk factors for development of pneumonia in patients with trauma sustained in a motor vehicle accident have been studied, the effect of prehospital time on pneumonia incidence post-trauma is unknown. RESEARCH QUESTION: Is prolonged prehospital time an independent risk factor for pneumonia? STUDY DESIGN AND METHODS: We retrospectively analyzed prospectively collected clinical data from 806,012 motor vehicle accident trauma incidents from the roughly 750 trauma hospitals contributing data to the National Trauma Data Bank between 2010 and 2016. RESULTS: Prehospital time was independently associated with development of pneumonia post-motor vehicle trauma (P < .001). This association was primarily driven by patients with low Glasgow Coma Scale scores. Post-trauma pneumonia was uncommon (1.5% incidence) but was associated with a significant increase in mortality (P < .001, 4.3% mortality without pneumonia vs 12.1% mortality with pneumonia). Other pneumonia risk factors included age, sex, race, primary payor, trauma center teaching status, bed size, geographic region, intoxication, comorbid lung disease, steroid use, lower Glasgow Coma Scale score, higher Injury Severity Scale score, blood product transfusion, chest trauma, and respiratory burns. INTERPRETATION: Increased prehospital time is an independent risk factor for development of pneumonia and increased mortality in patients with trauma caused by a motor vehicle accident. Although prehospital time is often not modifiable, its recognition as a pneumonia risk factor is important, because prolonged prehospital time may need to be considered in subsequent decision-making.

Abstract Purpose This article summarizes the appropriate use and pharmacology of treatments for fibrosing interstitial lung diseases, with a specific focus on the antifibrotic agents nintedanib and pirfenidone. Summary The interstitial lung diseases are a heterogenous group of parenchymal lung disorders with a common feature—infiltration of the interstitial space with derangement of the normal capillary-alveolar anatomy. Diseases characterized by fibrosis of the interstitial space are referred to as the fibrosing interstitial lung diseases and often show progression over time: idiopathic pulmonary fibrosis is the most common fibrotic interstitial lung disease. Historically, therapies for fibrosing lung diseases have been limited in number, questionable in efficacy, and associated with potential harms. Food and Drug Administration (FDA) approval of the antifibrotic agents nintedanib and pirfenidone for idiopathic pulmonary fibrosis in 2014 heralded an era of reorganization of therapy for the fibrotic interstitial lung diseases. Subsequent investigations have led to FDA approval of nintedanib for systemic sclerosis–associated interstitial lung disease and interstitial lung diseases with a progressive phenotype. Although supportive care and pulmonary rehabilitation should be provided to all patients, the role(s) of immunomodulators and/or immune suppressing agents vary by the underlying disease state. Several agents previously used to treat fibrotic lung diseases (N-acetylcysteine, anticoagulation, and pulmonary vasodilators) lack efficacy or cause harm. Conclusion With the introduction of effective pharmacotherapy for fibrosing interstitial lung disease, pharmacists have an increasingly important role in the interdisciplinary team managing these patients.

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Fluid balance and fluid management are complex issues affected by multiple patient variables. Positive net fluid balance has been correlated with increased mortality in sepsis. This study evaluated net fluid balance in patients with a diagnosis of sepsis at an academic medical center. METHODS: This study was approved by the Creighton University Institutional Review Board. We retrospectively reviewed the charts of 574 patients with sepsis who required >48 hours of ICU care in 2019. The primary outcome was mortality: secondary endpoints included SOFA score, ICU length of stay, site of infection, comorbidities, vasopressor use, and fluid balance at 24 hours, 72 hours, 7 days in the ICU, and cumulative fluid balance at ICU discharge. RESULTS: 199 patients met our inclusion criteria and were further analyzed; 51 (25.6%) died. Increased age (OR=1.28 for each 10-year increase, 95% CI: 1.01 to 1.62; P=0.042), increased SOFA scores (OR=1.26, 95% CI: 1.12 to 1.42; p<0.001), and pneumonia (OR=3.74, 95% CI: 1.63 to 8.60, P=0.002) were independent predictors of increased mortality. A higher net fluid balance at ICU discharge was associated with a statistically significant increase in mortality (OR=1.03 for each 500 mL increase, 95% CI: >1.00 to 1.05; P=0.022). Pneumonia was the source of sepsis in most patients (n=52, 26%). The relationship between fluid balance and mortality did not differ between pneumonia and non-pneumonia patients. CONCLUSIONS: The present retrospective analysis suggests that in patients diagnosed with sepsis a lower net fluid balance is associated with decreased mortality. Younger age and lower severity of illness were correlated with decreased mortality among patients with sepsis. CLINICAL IMPLICATIONS: Our study affirms that a thoughtful approach to fluid resuscitation should be utilized in septic critically ill patients, which may include judicious fluid administration and diuretic strategies to further improve patient outcomes. In addition, the relationship between pneumonia and fluid balance may warrant a more in-depth investigation. DISCLOSURES: No relevant relationships by Sarah Aurit, source=Web Response No relevant relationships by Khalid Bashir, source=Web Response No relevant relationships by Daniel Hilleman, source=Web Response No relevant relationships by Mark Malesker, source=Web Response No relevant relationships by Lee Morrow, source=Web Response No relevant relationships by Robert Plambeck, source=Web Response No relevant relationships by Abaigeal Tarpey, source=Web Response

Historically, the inhaled route of medication administration has been associated with the delivery of bronchodilators and/or corticosteroids to treat pulmonary conditions such as chronic obstructive pulmonary disease and asthma. However, this modality of drug delivery is increasingly being explored for use in other disease states, as drug inhalation is associated with several benefits including decreased systemic side effects, higher bioavailability, and more rapid absorption into the body. Certain inhaled medications that are used on- and off-label are encountered less frequently in daily medical practice than conventional bronchodilators. The most common on-label indications for inhaled medications include pulmonary arterial hypertension and pulmonary infections. The most reported off-label uses of inhaled medications include pulmonary infections, acute respiratory distress syndrome, pulmonary hemorrhage, and post-lung transplant.

BACKGROUND: Although resuscitation with IV fluids is the cornerstone of sepsis management, consensus regarding their association with improvement in clinical outcomes is lacking. RESEARCH QUESTION: Is there a difference in the incidence of respiratory failure in patients with sepsis who received guideline-recommended initial IV fluid bolus of 30 mL/kg or more conservative resuscitation of less than 30 mL/kg? STUDY DESIGN AND METHODS: This was a retrospective analysis of prospectively collected clinical data conducted at an academic medical center in Omaha, Nebraska. We abstracted data from 214 patients with sepsis admitted to a single academic medical center between June 2017 and June 2018. Patients were stratified by receipt of guideline-recommended fluid bolus. The primary outcome was respiratory failure defined as an increase in oxygen flow rate or more intense oxygenation and ventilation support; oxygen requirement and volume were measured at admission, 6 h, 12 h, 24 h, and at discharge. Subgroup analyses were conducted in high-risk patients with congestive heart failure (CHF) as well as those with chronic kidney disease (CKD). RESULTS: A total of 62 patients (29.0%) received appropriate bolus treatment. The overall rate of respiratory failure was not statistically different between patients who received appropriate bolus or did not (40.3% vs 36.8%; P = .634). Likewise, no differences were observed in time to respiratory failure (P = .645) or risk of respiratory failure (adjusted hazard ratio, 1.1 [95% CI, 0.7-1.7]; P = .774). Results were similar within the high-risk CHF and CKD subgroups. INTERPRETATION: In this single-center retrospective study, we found that by broadly defining respiratory failure as an increase in oxygen requirements, a conservative initial IV fluid resuscitation strategy did not correlate with decreased rates of hypoxemic respiratory failure.

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Studies have shown that ultrasound probes may serve as a medium for translocation. At our institution, we conducted a small pilot study of 20 patients showing translocation during point of care ultrasound (POCUS) can occur. However, the source and significance were not clear. We believe that careful consideration should be made to minimize the transmission of bacteria between patients, but standard disinfectant protocols were not established in our hospital and/or intensive care units. The purpose of this research was to examine the extent of contamination of an ultrasound probe and gel before and after encounters with patients, and to determine a best practice cleaning protocol. METHODS: Patients were randomly chosen from the critical care or hospital medicine service. Group 1, wiping the ultrasound probe off with a clean towel. Group 2, using a grey top disinfectant wipe after scanning. Statistically, we assumed an equal number of patients in the towel and disinfectant groups and assumed a positivity rate of 40% when a towel is used compared to 10% when the disinfectant is used, based on our initial pilot study results. We needed 50 total patients to have 80% power, with a total of 150 swabs (3 swabs per patient).Culture results were documented as being either positive or negative, species, number of colonies were also documented. Everything was standardized, including cart-based ultrasound and having the same individuals scan and swab patients. Prior to scanning, both groups had their probed disinfected with a disinfectant wipe. We used the BD E swab to culture the new bottle of gel each day. After disinfection, swab 1 (expect no growth) was used to culture the probe, prior to it being placed on the patient. The area of examination was standardized as well as contact time. The probe was swabbed after being placed on the patient, swab 2 (we would expect growth) and after either a dry towel or disinfectant wipe, swab 3 (we would expect no growth) was used to clean the probe. No probe was placed on broken skin. Growth medium was blood agar. Cultures were examined on day 1 and 3. RESULTS: A total of 50 patients. 150 cultures. 25 patients in each group. For the towel group, we had 10 patients with expected positive culture results on swab 2 and none of those patients had growth on swab 3 after decontamination with the towel. In the disinfectant wipe group, we had 12 patients with expected positive culture results on swab 2 with 2 colonies of Staphylococcus epidermidis and 15 colonies of Propionibacterium acnes that were reduced to one colony of Staphylococcus epidermidis on swab 3 after the disinfectant wipe was used. No gel swabs (n=15) showed positive growth. We had 4 unexpected culture results in the towel group and 2 unexpected culture results in the disinfectant wipe group which were believed to be contaminants, either showing positive on swab 1, after initial disinfection or swab 3(when swab 2 showed no growth and we would expect a positive culture). CONCLUSIONS: This study provides a reasonable discussion that disinfecting an ultrasound probe when used on non-broken skin with a clean towel is non-inferior to using a grey top disinfectant wipe. A more superior infection control protocol may include using a clean towel for initial decontamination, with use of a disinfectant wipe prior to next use. We also recommend use of a disinfectant wipe prior to new use. CLINICAL IMPLICATIONS: This study could help future POCUS infection control protocols DISCLOSURES: no disclosure on file for Brad DeVrieze; No relevant relationships by Evan Graumann, source=Web Response No relevant relationships by Jason Lambrecht, source=Web Response No relevant relationships by Paul Millner, source=Web Response No relevant relationships by Lee Morrow, source=Web Response No relevant relationships by Shraddha Narechania, source=Web Response No relevant relationships by Nicholas Sheridan, source=Web Response

Background: Little is known about hypoxemia surrounding endotracheal intubation in the critically ill. Thus, we sought to identify risk factors associated with peri-intubation hypoxemia and its effects’ on the critically ill. Methods: Data from a multicenter, prospective, cohort study enrolling 1,033 critically ill adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 were used to identify risk factors associated with peri-intubation hypoxemia and its effects on patient outcomes. We defined hypoxemia as any pulse oximetry ≤ 88% during and up to 30 minutes following endotracheal intubation. Results: In the full analysis (n = 1,033), 123 (11.9%) patients experienced the primary outcome. Five risk factors independently associated with our outcome were identified on multiple logistic regression: cardiac related reason for endotracheal intubation (OR 1.67, [95% CI 1.04, 2.69]); pre-intubation noninvasive ventilation (OR 1.66, [95% CI 1.09, 2.54]); emergency intubation (OR 1.65, [95% CI 1.06, 2.55]); moderate-severe difficult bag-mask ventilation (OR 2.68, [95% CI 1.72, 4.19]); and crystalloid administration within the preceding 24 hours (OR 1.24, [95% CI 1.07, 1.45]; per liter up to 4 liters). Higher baseline SpO2 was found to be protective (OR 0.93, [95% CI 0.91, 0.96]; per percent up to 97%). Consistent results were seen in a separate analysis on only stable patients (n = 921, 93 [10.1%]) (those without baseline hypoxemia ≤ 88%). Peri-intubation hypoxemia was associated with in-hospital mortality (OR 2.40, [95% CI 1.33, 4.31]; stable patients: OR 2.67, [95% CI 1.38, 5.17]) but not ICU length of stay (point estimate 0.9 days, [95% CI −1.0, 2.8 days]; stable patients: point estimate 1.5 days, [95% CI −0.4, 3.4 days]) after adjusting for age, body mass index, illness severity, airway related reason for intubation (i.e., acute respiratory failure), and baseline SPO2. Conclusions: Patients with pre-existing noninvasive ventilation and volume loading who were intubated emergently in the setting of hemodynamic compromise with bag-mask ventilation described as moderate-severe were at increased risk for peri-intubation hypoxemia. Higher baseline oxygenation was found to be protective against peri-intubation hypoxemia. Peri-intubation hypoxemia was associated with in-hospital mortality but not ICU length of stay. Trial registration: Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.