The primary objective of Airway management is to ensure adequate oxygenation and ventilation by securing a endotracheal tube without critical hypoxia or aspiration. Preoxygenation in the Emergency Department involves bringing the patients saturation as close to 100% as possible, to denitrogenate the residual capacity of the lungs (maximizing oxygen storage in the lungs) and maximally oxygenate the bloodstream. Conventional preoxygenation techniques may not be adequate in providing a safe apnea period in patients at high risk for desaturation or when an unanticipated difficult airway arises. Apneic oxygenation has been used as an adjunct to Rapid Sequence Intubation (RSI) which helps in reducing the desaturation. The principle behind the apneic oxygenation involves by providing continuous supply of oxygen to the upper airway, a reservoir of oxygen is maintained during apnea and this differential rate between alveolar oxygen absorption and carbon dioxide excretion generates a negative pressure gradient, which results in a ventilatory mass flow of gas from the upper respiratory tract into the lungs. Several types of oxygen devices used for apneic oxygenation includes Nasal cannula, High Flow Nasal Cannula, Nasopharyngeal oxygen insufflation, Buccal RAE Tube, Ventilator assisted preoxygenation.

           Several meta-analyses of apneic oxygenation studies have demonstrated a clinical benefit with the use of apneic oxygenation during emergent RSI. Apneic oxygenation serve as an non invasive adjunct to endotracheal intubation to decrease the incidence of hypoxemia, morbidity and mortality. Numerous studies of apneic oxygenation are described in the literature using modified laryngoscopes, nasopharyngeal catheters and nasal prongs. Nasal approaches in particular are increasing in popularity but are difficult in certain patient groups like trauma. Furthermore, some nasal catheter techniques (nasopharyngeal) have been associated with gastric rupture. Apneic oxygenation through Buccal oxygen administration via a modified Ring-Adair-Elwyn (RAE) tube would effectively extend safe apnea during prolonged laryngoscopy in obese patients.

           Various apenic oxygenation techniques have been compared to asses which could an ideal preoxygenation technique. Buccal versus nasal route has been compared in controlled operating room settings to find out safe apnea time, which concluded that buccal oxygenation via a modified RAE tube gives safe Apnea time higher than the Nasal cannula. Obesity, Trauma and many factors influence the apneic oxygenation through nasal route. Apneic oxygenation via nasal route has two disadvantages, one is that it has a longer route to the laryngeal inlet where we are targeting the flow of oxygen another is that any secretion, blood along the route can hinder the flow of oxygen. Another possible issue is that hypoxic patients might have their mouth open and this might lead to escape of at least some part of flow through the mouth when flow is delivered through nasopharynx. We hypothesize that the Buccal oxygenation can bypass the nasopharyngeal area and deliver oxygen directly in the pharyngeal inlet. There are no studies published till date regarding possibility of using buccal oxygenation as an alternate route for preventing incidence of hypoxia post endotracheal intubation during RSI. Buccal oxygenation with RAE tube could be an alternative to nasal cannula for apneic oxygenation during rapid sequence intubation in hypoxic patients presenting to emergency department. This method might be even the only possible oxygenation method in patients with maxillofacial injuries and obstructed nasal passage.