Nationwide survey on training and device utilization during tracheal intubation in French intensive care units

Abstract

Background: Intubation is a lifesaving procedure that is often performed in intensive care unit (ICU) patients, but leads to serious adverse events in 20-40% of cases. Recent trials aimed to provide guidance about which medications, devices, and modalities maximize patient safety. Videolaryngoscopes are being offered in an increasing range of options and used in broadening indications (from difficult to unremarkable intubation). The objective of this study was to describe intubation practices and device availability in French ICUs. Materials and methods:We conducted an online nationwide survey by emailing an anonymous 26-item questionnaire to physicians in French ICUs. A single questionnaire was sent to either the head or the intubation expert at each ICU.Results: Of 257 ICUs, 180 (70%) returned the completed questionnaire. The results showed that 43% of intubators were not fully proficient in intubation; among them, 18.8% had no intubation training or had received only basic training (lectures and observation at the bedside). Among the participating ICUs, 94.4% had a difficult intubation trolley, 74.5% an intubation protocol, 92.2% a capnography device (used routinely to check tube position in 69.3% of ICUs having the device), 91.6% a laryngeal mask, 97.2% front-of-neck access capabilities, and 76.6% a videolaryngoscope. In case of difficult intubation, 85.6% of ICUs used a bougie (154/180) and 7.8% switched to a videolaryngoscope (14/180). Use of a videolaryngoscope was reserved for difficult intubation in 84% of ICUs (154/180). Having a videolaryngoscope was significantly associated with having an intubation protocol (P = 0.043) and using capnography (P = 0.02). Airtraq ® was the most often used videolaryngoscope (39.3%), followed by McGrath ® Mac (36.9%) then by Glidescope ® (14.5%). Conclusion:Nearly half the intubators in French ICUs are not fully proficient with OTI. Access to modern training methods such as simulation is inadequate. Most ICUs own a videolaryngoscope, but reserve it for difficult intubations.

Neuromuscular blockade management in the critically Ill patient

“…The identification of the difficult airway is paramount, and its incidence may be over 11% [17]. Serious adverse events from attempted tracheal intubation performed in the ICU patients occur in up to 40% of cases [18]. In order to identify patients at risk of difficult intubation, some investigators have recommended development of simple scores that can be applied at bedside.…”

“…The scale for identification of risk factors for difficult airway/intubation in critically ill patients by nonanesthesiologist trainees was further refined and validated in a prospective, observational single-center study [19]. Despite the availability of indicators of difficult airway in ICU patients, however, a recent French survey found that 43% of intubating operators were still not fully proficient in the technique, with 18.8% of them having had no intubation training, or only basic training, such as lectures or observation [18]. This survey also reported that although video laryngoscopy is available in most of the French ICUs, its use was reserved for management of the difficult airway patients [18].…”

“…Despite the availability of indicators of difficult airway in ICU patients, however, a recent French survey found that 43% of intubating operators were still not fully proficient in the technique, with 18.8% of them having had no intubation training, or only basic training, such as lectures or observation [18]. This survey also reported that although video laryngoscopy is available in most of the French ICUs, its use was reserved for management of the difficult airway patients [18]. Remarkably, the vast majority (83%) of intensivists had placed less than a total of 10 laryngeal mask airways, and half had performed less than 10 intubations using fiberoptic bronchoscopy, despite the fact that a majority (87%) of clinicians expressed a desire to participate in high fidelity mannequin simulations [20].…”

Effect of endotracheal tube plus stylet versus endotracheal tube alone on successful first-attempt tracheal intubation among critically ill patients: the multicentre randomised STYLETO study protocol

“…We chose not to allow videolaryngoscopy for the first-attempt of intubation, to avoid confounding factors regarding the association between stylet use and first-attempt success. 2 37 38 Besides, according to recent data showing the results of an online nationwide survey in 180 French ICUs, 39 the videolaryngoscopy was used for the first attempt in only 8 (4%) ICUs. Therefore, the external validity of our study will be higher focussing on Macintosh direct laryngoscopy for first-attempt success.…”

Prone Position after Liberation from Prolonged Mechanical Ventilation in COVID-19 Respiratory Failure

“…Conscious prone positioning garnered renewed interest in the face of the COVID-19 pandemic as a means of improving oxygenation and avoiding intubation [ 9 – 12 ]. Conscious prone positioning has also been described in neonates [ 13 ], as well as perioperative patients, as a means of improving secretion clearance and avoiding intubation [ 14 ].…”