Role of Prophylactic Endotracheal Intubation in Severe Upper Gastrointestinal (GI) Bleeding: An Updated Systemic Review and Meta-Analysis

Abstract

Introduction: Upper GI bleeding needing intensive care unit admission carries a significant risk of mortality and disease burden. Airway management to prevent aspiration during ongoing severe upper GI bleeding remains controversial and lacks evidence based guidelines. A consideration for prophylactic endotracheal intubation (PI) based on clinical judgement is recommended by most gastrointestinal societies. Evidence based guidelines at lacking in this area. A previous meta-analysis tried to address this question, however, it included only two published studies and two abstracts. New studies are available since last publication, hence the need for updated meta-analysis. Methods: On January 30,2017, we conducted a systematic search of Medline, EMBASE, Web of Science Collection databases and the Cochrane Central Register of Controlled Trials for fully published studies in English literature which involved patients with upper GI bleeding and compared complications of prophylactic intubation before endoscopy versus no intubation before the procedure. Studies which included pediatric population or lacked control arm were excluded. The primary outcome of interest was comparison of aspiration pneumonia and mortality between the two groups. Secondary outcome of interest was witnessed aspiration. Mantel-Haenszal method for fixed effect model and DerSimonian and Laird method for random effects model was used to calculate odds ratio (OR) for these outcomes. Duval and Tweedie's Trim and Fill test was used to detect any publication bias. RevMan 5.3 and CMA version 3.0 was used for statistical analyses Results: Our search identified 167 studies. Out of these 11 studies were relevant and 6 fully published studies met our inclusion criteria. Five studies reported outcomes for aspiration pneumonia. Using random effects model, our analysis for aspiration pneumonia showed significantly higher risk of aspiration pneumonia with 48 hours in patients who underwent prophylactic intubation before EGD compared to those who did not (Odds ratio OR, 4.0; 95% confidence interval CI, 1.15 - 14.2). We experienced moderate heterogeneity in our analysis (I2= 53%) which is attributed to varying baseline characteristics of included patient population. No significant publication bias was noted in this analysis. A higher mortality was noted in patients who underwent prophylactic intubation before EGD (Odds ratio, OR 1.37; 95% CI, 1.11-1.69). There was no difference in aspiration between the two groups (OR 1.45, 95% CI 0.58-3.62). Conclusion: Patients undergoing prophylactic intubation in severe upper GI bleeding has a higher odds aspiration pneumonia and mortality. A routine use of prophylactic intubation before EGD in severe upper GI bleeding should be discouraged.Figure: Forest Plot Comparing Aspiration in Prophylactic Intubation Versus No Intubation.Figure: Funnel Plot Comparing Aspiration in Prophylactic Intubation Versus No Intubation.Figure: Forest Plot Comparing Mortality in Prophylactic Intubation Versus No Intubation.