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Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries

Educational Objective
To understand the frequency of adverse events associated with tracheal intubation.
1 Credit CME
Key Points

Question  Among critically ill patients undergoing tracheal intubation worldwide, how common are major adverse events during the peri-intubation period?

Findings  In this prospective observational study that included 2964 patients from 197 sites across 29 countries from October 2018 to July 2019, at least one major clinical event occurred after intubation in 45.2% of patients, including cardiovascular instability in 42.6%, severe hypoxemia in 9.3%, and cardiac arrest in 3.1%.

Meaning  Among an international sample of critically ill patients undergoing tracheal intubation, major cardiopulmonary events occurred frequently.

Abstract

Importance  Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events.

Objective  To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients.

Design, Setting, and Participants  The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents.

Exposures  Tracheal intubation.

Main Outcomes and Measures  The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality.

Results  Of 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%.

Conclusions and Relevance  In this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events—in particular cardiovascular instability—were observed frequently.

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Article Information

Corresponding Author: John G. Laffey, MD, MA, Anesthesia and Intensive Care Medicine, School of Medicine, University Hospital Galway, 1-008 Clinical Sciences Institute, NUI Galway, Costello Rd, Newcastle, Galway, Ireland (john.laffey@nuigalway.ie).

Accepted for Publication: February 2, 2021.

Author Contributions: Drs Russotto and Tassistro had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Russotto, Myatra, Laffey, Antolini, Szuldrzyiski, Camporota, Pelosi, Higgs, Greif, Fumagalli, Pesenti, Foti, Bellani.

Acquisition, analysis, or interpretation of data: Russotto, Myatra, Laffey, Tassistro, Antolini, Bauer, Lascarrou, Szuldrzyiski, Sorbello, Putensen, Agvald-Öhman, Chalkias, Bokums, Brewster, Rossi, Foti, Bellani.

Drafting of the manuscript: Russotto, Myatra, Laffey, Tassistro, Lascarrou, Camporota, Higgs, Foti.

Critical revision of the manuscript for important intellectual content: Russotto, Myatra, Laffey, Antolini, Bauer, Lascarrou, Szuldrzyiski, Camporota, Pelosi, Sorbello, Greif, Putensen, Agvald-Öhman, Chalkias, Bokums, Brewster, Rossi, Fumagalli, Pesenti, Bellani.

Statistical analysis: Russotto, Laffey, Tassistro, Antolini, Rossi, Foti.

Obtained funding: Bellani.

Administrative, technical, or material support: Russotto, Laffey, Camporota, Putensen, Agvald-Öhman, Chalkias, Brewster, Bellani.

Supervision: Russotto, Myatra, Laffey, Lascarrou, Pelosi, Sorbello, Higgs, Greif, Putensen, Fumagalli, Pesenti, Bellani.

Conflict of Interest Disclosures: Dr Laffey reported receiving personal fees from Baxter Healthcare and institutional grants from Science Foundation Ireland. Dr Lascarrou reported receiving personal fees from Becton, Dickinson, and Co and Zoll. Dr Sorbello reported receiving personal fees from Teleflex Medical, Merck Sharp & Dohme, Verathon Medical, and other support from Deas Italia (patent coowner no royalties) outside the submitted work. Dr Putensen reported receiving grants from the German Research Foundation Electric Impedance Tomography outside the submitted work. Dr Pesenti reported receiving personal fees from Maquet, Novalung-Xenios, Baxter, and Boehringer Ingelheim. Dr Bellani reported receiving grants from Draeger Medical and personal fees from Dimar, Draeger Medical, Getinge, Flowmeter, Hamilton, and GE Healthcare and having a patent pending for a system for noninvasive ventilation. No other disclosures were reported.

Funding/Support: This study was funded and supported by the University of Milano-Bicocca, Monza, Italy.

Role of the Funder/Sponsor: University of Milano-Bicocca had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: INTUBE Study Investigators are listed in the Supplement.

Additional Contributions: We thank Davide Gaudesi, PhD, from the University of Milano-Bicocca for his support in the electronic case report form development and management. He did not receive any compensation for this work. We also thank Valeria Meroni, MD, Francesca Rabboni, MD, and Manuela Marotta, MD, all from the University of Milan–Bicocca, for their support in data checking and monitoring. None of them received compensation for their contribution.

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