High frequency of intubation-related major events in critically ill patients: INTUBE

The frequency of tracheal intubation-related major adverse events, including cardiovascular instability, was high in a cohort of critically ill patients in the international INTUBE study.

“Tracheal intubation is one of the most commonly performed urgent procedures in critically ill patients,” John G. Laffey, MD, professor at the National University of Ireland Galway School of Medicine and consultant in intensive care medicine and anesthesia at Galway University Hospital, said during a presentation during the virtual Society for Critical Care Medicine Critical Care Congress. “There are a limited number of prospective national-level studies available and, of those that do exist, it implicates that 28% of procedures can be complicated by major adverse events. There is relatively limited information available on practice and peri-intubation events in routine clinical practice from large international cohorts.”

Researchers conducted the international, multicenter, prospective, observational cohort INTUBE study of consecutive critically ill patients undergoing intubation in the ICU, ED and ward from October 2018 to July 2019. The study enrolled 2,964 critically ill patients (median age, 63 years; 37% women; median SOFA score, 7) who underwent 3,058 intubation procedures, including 94 reintubations. All patients were followed for 30 minutes post-intubation and 2,943 patients were followed until ICU discharge.

The primary outcome was the presence of severe hypoxemia, cardiac arrest or CV instability within 30 minutes of the start of the procedure. Secondary outcomes included ICU mortality, arrhythmia, intubation characteristics, pulmonary aspiration and airway injury.

The primary reasons for intubation were respiratory failure in 52% and neurological impairment in 30%.

Forty-two percent of patients experienced severe CV instability, 3.1% experienced cardiac arrest and 9.3% experienced severe hypoxemia. Severe CV instability was mainly seen as new need or increase of vasopressors (35.5%).

Secondary events including esophageal intubation, new-onset cardiac arrhythmia, difficult intubation and aspiration of gastric contents occurred in 3% to 5% of patients.

Those who experienced major intubation events had a significantly lower survival probability compared with patients who did not experience these events (P < .0001). Probability of survival was also lower among patients with intubation-related CV instability and intubation-related cardiac arrest compared with patients without (P < .0001 for both). Survival was not different between patients with and without severe hypoxemia (P = .41).

Repeated intubation in these critically ill patients was associated with an increased risk for adverse events, particularly for cardiac arrest and severe hypoxemia.

The preoxygenation method used in most patients was bag-mask ventilation (62%); apneic oxygenation was used in 10.4%. Video laryngoscopy was only used in 17.1% of patients. Waveform capnography was the first method used to confirm tracheal intubation in 25.6% of patients. Laffey noted that use of waveform capnography varied depending on the location in which tracheal intubation occurred, with the highest levels of use in the ICU (40%).

The INTUBE study was performed at 197 sites across 29 countries. “The findings provide a “good global picture of the current approaches to emergent tracheal intubation,” Laffey said.

“Future study directions should focus on interventions targeting perioperative or peri-intubation hemodynamics,” Laffey said.