Prophylactic Tracheal Intubation Versus No Intubation for Upper GI Bleeding: Is There a True Difference in Patient Outcomes? A Meta-Analysis

Abstract

Introduction: Upper gastrointestinal bleeding (UGIB) is a serious condition that accounts for large volume of hospital and intensive care unit admissions each year. Endoscopy is the key diagnostic and therapeutic intervention for UGIB. Although significant morbidity and mortality can result from pulmonary aspiration that may complicate endoscopy, only a few studies have been conducted to evaluate the effect of prophylactic endotracheal intubation on such complication. We performed a meta-analysis on the outcomes of prophylactic endotracheal intubation versus no prophylactic intubation prior to endoscopy in patients with UGIB. Methods: A comprehensive search of PubMed/MEDLINE, Embase, Scopus, CINAHL, Cochrane databases, and published abstracts from Digestive Disease Week and the American College of Gastroenterology national meetings (2004 to 2014) was performed (May 2014). All studies comparing prophylactic intubation versus no prophylactic intubation in patients with endoscopy for UGIB were included. Two authors independently extracted the data. Meta-analysis was performed using fixed and random effects models with odds ratio (OR) to assess for mortality, pneumonia within 48 hours, and aspiration. Publication bias was assessed using funnel plots. We assessed heterogeneity by calculating the I2 measures of inconsistency. RevMan 5.2 was utilized for statistical analysis. Results: Four studies met the inclusion criteria (N=367). Patients that were prophylactically intubated prior to endoscopy for UGIB experienced a statistically significant increase in pneumonia within 48 hours as compared to patients not prophylactically intubated (OR 3.13; 95% CI: 1.17-8.39; p=0.02). Although trends were noted toward worse outcomes with prophylactic intubation, no statistically significant differences were noted for aspiration (OR 3.99; 95% CI: 0.72-22.12; p=0.11) or mortality (OR 2.19; 95% CI: 0.69-6.95; p=0.18) between the two groups. Conclusion: Patients prophylactically intubated prior to endoscopy for UGIB are more likely to develop pneumonia within 48 hours than patients not prophylactically intubated. Furthermore, nonsignificant trends toward increased mortality and aspiration were observed. A randomized controlled trial is necessary to assess this issue of prophylactic intubation prior to endoscopy in patients with UGIB. Disclosure - Dr. Bechtold - Consultant: Nestle Nutrition Institute.