Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials

Abstract

BackgroundWe performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill.MethodsWe searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation-based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration’s Risk of Bias tool.ResultsWe identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study). Pre-oxygenation with non-invasive ventilation (NIV) and/or high-flow nasal cannula (HFNC) showed a possible beneficial role. Post-intubation recruitment improved oxygenation, while ramped position increased the number of intubation attempts and thiopental had negative hemodynamic effects. No effect was found for use of a checklist, apneic oxygenation (on oxygenation and hemodynamics), videolaryngoscopy (on number and length of intubation attempts), sedatives and neuromuscular blockers (on hemodynamics). Finally, videolaryngoscopy was associated with severe adverse effects in multiple trials.ConclusionsThe limited available evidence supports a beneficial role of pre-oxygenation with NIV and HFNC before intubation of critically ill patients. Recruitment maneuvers may increase post-intubation oxygenation. Ramped position increased the number of intubation attempts; thiopental had negative hemodynamic effects and videolaryngoscopy might favor adverse events.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1927-3) contains supplementary material, which is available to authorized users.

Emergency intubation of children outside of the operating room

“…Oxygen desaturation is the most common reason for aborted first attempt at intubation, both of which increase the risk of further life‐threatening adverse events. Inadequate resuscitation prior to intubation and failure to use strategies to mitigate physiological derangements prior to and during intubation may increase the risk of life‐threatening adverse events …”

Approach to the Airway in the Emergency Department (ED) and Intensive Care Unit (ICU) in a Portuguese University Hospital Center: a prospective observational study

“…Airway management is a commonly performed procedure in the ED and ICU, being tracheal intubation the gold standard. Several studies identify relatively high rates of complications in these settings, ranging from 20 to 31% in ICUs [1], which can be life-threatening, including severe hypoxia, hemodynamic collapse, cardiac arrest and death [2]. This pool of patients differs from those in elective surgery intubated in the operating room taking into account that they often present with severe respiratory failure, hemodynamic instability, absence of a fasting state and other comorbilities [2].…”

“…Several studies identify relatively high rates of complications in these settings, ranging from 20 to 31% in ICUs [1], which can be life-threatening, including severe hypoxia, hemodynamic collapse, cardiac arrest and death [2]. This pool of patients differs from those in elective surgery intubated in the operating room taking into account that they often present with severe respiratory failure, hemodynamic instability, absence of a fasting state and other comorbilities [2]. In general, hypoxemia is common in patients requiring intubation and care should be given to its quick performance to avoid aspiration [3] and further dessaturation, given that previous studies reported a significant increase in hypoxemia with the increase in laryngoscopic attempts [3].…”

“…Further circumstances contribute to high incidence of difficult intubation when compared to elective intubation in the operating room [2]. Intubation of criticall ill patients is impaired by lack of training and assistance, unrecognition of patients at risk, failure to plan and to lead an alternative approach, if necessary, and few resources concerning available equipment and the limited space around ICU beds [2].…”

Integration of Pre-intubation Ultrasound into Airway Management Course: A Novel Training Program

“…It is recommended to include a cardiovascular component in the protocol during intubation of ICU patients, by defining volume responsiveness and early administration of vasopressors to prevent hemodynamic collapse. [14][15][16] Optimizing the hemodynamics prior to intubation is crucial to prevent cardiovascular complications in the periintubation period. The information obtained by performing a brief bedside cardiac ultrasound can change the management of critically ill patient, preventing potential decompensation during and following endotracheal intubation.…”