Intubation In Intensive Care Unit Research Articles

Design and application of alaryngeal mask and monitoring device facilitating withdrawal of endotracheal tube

Percutaneous dilatational tracheostomy (PDT) is a surgical method for quickly establishing an artificial airway, which has been favored by clinicians because of its simple operation, small trauma and bedside operation. However, for patients with tracheal intubation in intensive care unit (ICU), the tip and balloon of the existing endotracheal tube will not only hinder percutaneous puncture, but also hinder insertion of guidewire and tracheotomy tube, and consequently affect the process of PDT. On the contrary, blind withdrawal of the existing endotracheal tube may cause the tracheal tube tipleave the glottis, leading to an emergency airway situation that endangers the patient's life. Therefore, the medical staff from intensive care medicine department of the First People's Hospital of Chenzhou designed a laryngeal mask and its monitoring device, which is convenient for withdrawal of endotracheal tube, and obtained the national utility model patent of China (patent number: ZL 2020 2 2795887.1). The device is composed of a laryngeal mask and a monitoring device. The laryngeal mask mainly includes a laryngeal mask body, a vent tube, a guidance tube and other components. The laryngeal mask body is mainly used to seal the throat and provide the air supply channel for the patient together with the ventilation tube. The main function of the guidance tube is to accommodate the tracheal tube and facilitate the withdrawal of the inserted tracheal tube. During percutaneous dilatation tracheotomy, this device can monitor the withdrawal of tracheal catheter in real time, and immediately ensure the airway patency of patients without re-intubation when the cuff of tracheal catheter exits the glottis. The utility model has the advantages of real-time monitoring, simple operation, safety and convenience, and is worthy of transformation and promotion.

Meta-analysis of the influence of tracheal intubation with cuff and without cuff on the incidence of total wound complications in ICU intubation patients.

At present, it is still controversial whether patients in intensive care unit (ICU) use tracheal intubation with or without cuff. This paper evaluates the effect of tracheal intubation with and without cuff on overall complication rate of patients with intubation in ICU. The database of PubMed, Embase, Conchrane Library and Web of Science was searched by computer, and the clinical research on intubation with and without cuff in ICU was collected. The time range was from the database establishment to November 2023. Literature was independently screened, information was extracted, and quality was assessed by two researchers. Finally, there were nine studies included, with 11 068 patients (7391 in cuff group and 3677 in non-cuff group). The results showed that the overall complication rate of cuff group was significantly lower than that of non-cuff group, and that of cuff group (RR = 0.53, p < 0.01). In addition, compared with the non-cuff group, the cuff group had a lower number of tracheal intubation changes [RR = 0.05, p < 0.01] and a lower incidence of aspiration pneumonia (RR = 0.45, p = 0.01). Compared with the non-cuff group, the cuff group had a higher incidence of oral mucosal ulcers and pharyngitis (RR = 1.99, p = 0.04), while the cuff group had a lower incidence of laryngeal edema (RR = 0.39, p < 0.01). In ICU intubation patients, the use of cuffs reduces overall complication rate in comparison to patients without cuffs. Therefore, patients with intubation in ICU can recommend tracheal intubation with cuff.

Sanyar Video Laryngoscope Improved Time and First Pass Success of Tracheal Intubation in Intensive Care Unit in Compared to Direct Laryngoscopy

Background: Airway management and tracheal intubation in the ICU is a difficult procedure that may be concomitant with major complications. The purpose of this study was to evaluate the effect of the SANYAR ® video laryngoscope(S-VL) on laryngeal view and first Pass Success of tracheal Intubation compared with direct laryngoscopy.&#x0D; Methods: This comparative, prospective clinical study was conducted on 120 adult patients in a single-center, in a surgical ICU under the supervision of an anesthesiologist in a university hospital. Difficult airway predictors, glottic view, first Pass Success of tracheal Intubation and time of intubation were evaluated with Macintosh laryngoscopy (ML) or the SANYAR® Video Laryngoscope(S-VL).&#x0D; Results: Tracheal intubation was performed in 58 critically ill patients using ML and 62 patients using S-VL. According to Cormack and Lehane (C&amp;L) grading glottic visualization was more difficult using ML (41%, C&amp;L grade 3 and 4) compared with S-VL (13%, C&amp;L grade 3 and 4) p&lt;0.001. Intubation of trachea was more successful in the first attempt, in patients with at least one difficult airway predictor with a S-VL compared to ML (87% vs. 38%; P = 0.001), time of intubation was also shorter by using S-VL.&#x0D; Conclusion: Among critically ill patients in the intensive care unit, who require intubation, the SANYAR video laryngoscopy improved glottis view compared to the Macintosh direct laryngoscopy and first-pass orotracheal intubation rate especially in patients with potentially difficult airways.

No: 1663 Difficult intubation in intensive care units: are we feeling ready enough?

No: 1663 Difficult intubation in intensive care units: are we feeling ready enough?

Design and application of flushing device of a totally enclosed sputum suction tube for reducing the incidence of ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is one of the most common infectious diseases in patients undergoing mechanical ventilation in intensive care unit (ICU). Although the use of closed sputum suction tube for sputum suction is the most common nursing measure for patients with tracheal intubation in ICU, and it is also an important measure to reduce the occurrence of VAP, the existing clinical technology still needs to use external flushing solution for humidification and flushing. In the process of use, the flushing operation has the risk that the amount of flushing fluid cannot be controlled, resulting in a large amount of flushing fluid entering the patient's airway, causing the patient to suffocate. The sputum attached to the wall of the sputum suction tube cannot be completely flushed, and the prolonged retention of the sputum leads to the proliferation of colonized bacteria, aggravating the infection of patients. Repeated pipe flushing not only increases consumables, but also increases the workload of medical staff. For this reason, the author has designed a fully enclosed sputum suction tube flushing device, which has obtained the National Utility Model Patent of China (patent number: CN 2019 2 1198740.5). This device is an integrated design, and the materials used for sputum suction, humidification and flushing are fully enclosed, without air exposure, and can be operated strictly without bacteria. Pulse flushing with syringe can clean the sputum attached to the inner wall and reduce the incidence of VAP. The volume of flushing fluid can be effectively controlled during use to ensure patient safety and reduce waste. It is worth popularizing and applying in clinical practice to optimize the operation steps and reduce the workload of medical staff.

Airway management in the critically ill patient with COVID-19.

Critically ill Coronavirus disease 2019 (COVID-19) patients needing endotracheal intubation are on the verge of rapid decompensation. The aims of this review were to assess the risks, the preoxygenation, the device and the hemodynamic management of a patient with COVID-19. The proceduralist performing endotracheal intubation with the entire team are at an increased risk for exposure to COVID-19. Appropriate personal protective equipment and other measures remain essential. For preoxygenation, noninvasive ventilation allows higher oxygen saturation during intubation in severely hypoxemic patients and can be associated with apneic oxygenation and mask ventilation during apnea in selected cases. The COVID-19 pandemic has further highlighted the place of videolaryngoscopy during intubation in intensive care unit (ICU). Hemodynamic optimization is mandatory to limit hypotension and cardiac arrest associated with airway management. Future trials will better define the role of videolaryngoscopy, apneic oxygenation and mask ventilation during apnea for intubation of COVID-19 patients in ICU. The use of fluid loading and vasopressors remains to be investigated in large randomized controlled studies. Choosing the right time for intubation remains uncertain in clinical practice, and future works will probably help to identify earlier the patients who will need intubation.

Endotracheal intubation sedation in the intensive care unit.

Endotracheal intubation is one of the most common, yet most dangerous procedure performed in the intensive care unit (ICU). Complications of ICU intubations include severe hypotension, hypoxemia, and cardiac arrest. Multiple observational studies have evaluated risk factors associated with these complications. Among the risk factors identified, the choice of sedative agents administered, a modifiable risk factor, has been reported to affect these complications (hypotension). Propofol, etomidate, and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal intubation. Propofol demonstrates rapid onset and offset, however, has drawbacks of profound vasodilation and associated cardiac depression. Etomidate is commonly used in the critically ill population. However, it is known to cause reversible inhibition of 11 β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 h. This added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its use. Ketamine is known to provide analgesia with sedation and has minimal respiratory and cardiovascular effects. However, its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant hallucinations. Moreover, unlike propofol or etomidate, ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ill. Lately, a combination of ketamine and propofol, “Ketofol”, has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent drugs. Furthermore, the doses of both drugs are reduced. In situations where a difficult airway is anticipated, awake intubation with the help of a fiberoptic scope or video laryngoscope is considered. Dexmedetomidine is a commonly used sedative agent for these procedures.

Role and significance of tracheotomy in intensive care units in coronavirus disease 2019-positive patients

Introduction. The role of tracheotomy in the treatment of patients with prolonged intubation in intensive care units is known and confirmed. In light of the global pandemic of severe acute respiratory syndrome coronavirus-2 infection and consequent coronavirus disease 2019, we present our experiences with tracheotomy in infected patients. Material and Methods. A retrospective observational study of patients treated in intensive care units at the Clinical Hospital Center ?Dr. Dragisa Misovic Dedinje? was carried out in the period from March 21, 2020 to May 14, 2020. Results. A total of 970 coronavirus disease 2019-positive patients were treated and out of that number, 116 patients were treated in intensive care units (12%), of which 49 patients (42%) were on non-invasive mechanical ventilation and 67 patients (58%) on intensive mechanical ventilation. The average age of the patients was 59.3 years; the youngest patient was 46, and the oldest 73 years old. Tracheotomy was performed in 24 patients (21%), in 13 males (54.1%) and 11 females (45.9%). The mean time from intubation to tracheotomy was 11.6 days. Of the 24 tracheotomized patients, 12 had a successful decannulation (50%) and were discharged from intensive care units, 6 had a lethal outcome, and 6 patients were in treatment. Discussion. All the patients underwent tracheotomy in the hospital room, because we considered that any transfer and manipulation of these severe patients may lead to worsening of the generally serious condition. Although some guidelines recommend that it would be ideal to know the coronavirus disease 2019 status before any invasive procedure, we believe that this is not necessary, especially considering the clinical picture of patients during the pandemic, as well as computed tomography findings in the lungs. Conclusion. Tracheotomy has an important place in the treatment of patients with severe coronavirus disease 2019 infection since it provides easier maintenance of the airway, and in the recovery phase leads to easier transition of patients from mechanical ventilation to spontaneous breathing. The decision on the day when the tracheotomy will be performed is strictly individual and depends on the general condition of the patient, and the use of thermocautery does not affect the course of treatment and the final outcome.

Bag-Mask Ventilation Versus Apneic Oxygenation During Tracheal Intubation in Critically Ill Adults: A Secondary Analysis of 2 Randomized Trials.

Background: Hypoxemia is common during tracheal intubation in intensive care units. To prevent hypoxemia during intubation, 2 methods of delivering oxygen between induction and laryngoscopy have been proposed: bag-mask ventilation and supplemental oxygen delivered by nasal cannula without ventilation (apneic oxygenation). Whether one of these approaches is more effective for preventing hypoxemia during intubation of critically ill patients is unknown. Methods: We performed a secondary analysis of data from 138 patients enrolled in 2, consecutive randomized trials of airway management in an academic intensive care unit. A total of 61 patients were randomized to receive bag-mask ventilation in a trial comparing bag-mask ventilation to none, and 77 patients were randomized to receive 100% oxygen at 15 L/min by nasal cannula in a trial comparing apneic oxygenation to none. Using multivariable linear regression accounting for age, body mass index, severity of illness, and oxygen saturation at induction, we compared patients assigned to bag-mask ventilation with those assigned to apneic oxygenation regarding lowest oxygen saturations from induction to 2 min after intubation. Results: Patients assigned to bag-mask ventilation and apneic oxygenation were similar at baseline. The median lowest oxygen saturation was 96% (interquartile range [IQR] 89%-100%) in the bag-mask ventilation group and 92% (IQR 84%-99%) in the apneic oxygenation group. After adjustment for prespecified confounders, bag-mask ventilation was associated with a higher lowest oxygen saturation compared to apneic oxygenation (mean difference, 4.2%; 95% confidence interval, 0.7%-7.8%; P = .02). The incidence of severe hypoxemia (oxygen saturation<80%) was 6.6% in the bag-mask ventilation group and 15.6% in the apneic oxygenation group (adjusted odds ratio, 0.33; P = .09). Conclusions: This secondary analysis of patients assigned to bag-mask ventilation and apneic oxygenation during 2 clinical trials suggests that bag-mask ventilation is associated with higher oxygen saturation during intubation compared to apneic oxygenation.

Emergency intubation practices in a tertiary teaching hospital in Jakarta, Indonesia: A prospective observational study.

Intubation is an important competency for emergency doctors. Emergency patients are often unstable, with undifferentiated conditions. There is little time to prepare these patients prior to intubation and so ED intubation may differ from intubation in intensive care units and operating theatres. The present study aims to describe the characteristics of emergency intubation after an administrative policy change within a tertiary teaching hospital in Jakarta, allowing non-anaesthetists to perform intubation in the ED. Prospective data were collected regarding patients of all age groups who were intubated at the ED of Cipto Mangunkusumo General Hospital, Jakarta, from February 2018 to January 2019. Patient characteristics, intubation attempts, medications used, complications, and disposition were recorded in a self-reported airway registry based on the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR) form. During the 12-month study period, 231 patients, or 41.5% of ED intubated patients were enrolled in the study, and there were 268 intubation attempts on these enrolled patients. The first-pass success rate was 207 out of 231 patients, or 89.6%, with anaesthetist (88.9%), better than emergency doctors (55.4%). Complications were reported in 51 patients, or 22.0%, with desaturation and hypotension being the most common. Thirty-three patients, or 14.3%, died in the ED before being transferred to another unit. The first-pass success rate is comparable with international data. Non-anaesthetic physicians must improve their experience to achieve a favourable success rate. The data on complications highlight the need for improvement in Indonesian ED intubation practices.

Benefits and challenges associated with the timing of tracheostomy in critically ill patients: experience at a tertiary intensive care unit

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Prolonged intubation in intensive care units (ICU) leads to damage to the airways. Tracheostomy is performed with an aim to facilitate pulmonary toileting and also protect the upper airways from the associated ill effects of prolonged endotracheal intubation. The timing of this procedure is a matter of considerable debate and varies according to different centres.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 50 patients were assessed. 34 belonged to the early group and 16 belonged to the late group. The study was carried out in the ICU of a tertiary care referral centre. The timing of occurrence of ventilator associated pneumonia (VAP), duration of ICU stay and duration of tracheostomy and the was compared between the early and late groups respectively.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; It was found that early tracheostomy leads to reduced ICU stay and delayed occurrence of VAP. The results were statistically significant. Additionally, it was also observed in this study that early tracheostomy leads to reduced duration of tracheostomy as compared to the late group although not statistically significant.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Due to large clinical heterogeneity amongst cases admitted to the ICU, the timing of tracheostomy is different in different centres. Hence, guidelines need to be formulated in order to perform tracheostomy in critically ill patients in order to prevent the demerits associated with late tracheostomy such as prolonged ICU stay, early occurrence of VAP and late decannulation. In addition to this, economic advantages also need to be considered as most of the population in developing countries do not have universal health insurance.&lt;/p&gt;

Variation in Intensive Care Unit Intubation Practices in Pulmonary Critical Care Medicine Fellowship.

Background: Endotracheal intubation in the intensive care unit (ICU) is a high-risk procedure. Competence in endotracheal intubation is a requirement for Pulmonary and Critical Care Medicine (PCCM) training programs, but fellow experience as the primary operator in intubating ICU patients has not been described on a large scale.Objective: We hypothesized that significant variation surrounding endotracheal intubation practices in medical ICUs exists in U.S. PCCM training programs.Methods: We administered a survey to a convenience sample of U.S. PCCM fellows to elicit typical intubation practices in the medical ICU.Results: Eighty-nine discrete U.S. PCCM and Internal Medicine Critical Care Medicine training programs (77% response rate) were represented. At 43% of programs, the PCCM fellow was “always or almost always” designated the primary operator for intubation of a medical ICU patient, whereas at 21% of programs, the PCCM fellow was “rarely or never” the primary operator responsible for intubating in the ICU. Factors influencing this variation included time of day, hospital policies, attending skill or preference, ICU census and acuity, and patient factors. There was an association between location of the training program, but not program size, and whether the PCCM fellow was the primary operator.Conclusion: There is significant variation in whether PCCM fellows are the primary operators to intubate medical ICU patients during training. Further work should explore how this variation affects fellow career development and competence in intubation.

Association of Delivery Room and Neonatal Intensive Care Unit Intubation, and Number of Tracheal Intubation Attempts with Death or Severe Neurological Injury among Preterm Infants.

The study aimed to assess the association of tracheal intubation (TI) and where it is performed, and the number of TI attempts with death and/or severe neurological injury (SNI) among preterm infants. Retrospective cohort study of infants born 23 to 32 weeks, admitted to a single level-3 neonatal intensive care unit (NICU) between 2015 and 2018. Exposures were location of TI (delivery room [DR] vs. NICU) and number of TI attempts (1 vs. >1). Primary outcome was death and/or SNI (intraventricular hemorrhage grade 3-4 and/or periventricular leukomalacia). Multivariable logistic regression analysis was used to assess association between exposures and outcomes and to adjust for confounders. Rate of death and/or SNI was 2.5% (6/240) among infants never intubated, 12% (13/105) among NICU TI, 32% (31/97) among DR TI, 20% (17/85) among infants with one TI attempt and 23% (27/117) among infants with >1 TI attempt. Overall, median number of TI attempts was 1 (interquartile range [IQR]: 1-2). Compared with no TI, DR TI (adjusted odds ratio [AOR]: 9.04, 95% confidence interval [CI]: 3.21-28.84) and NICU TI (AOR: 3.42, 95% CI: 1.21-10.61) were associated with higher odds of death and/or SNI. The DR TI was associated with higher odds of death and/or SNI compared with NICU TI (AOR: 2.64, 95% CI: 1.17-6.22). The number of intubation attempts (1 vs. >1) was not associated with death and/or SNI (AOR: 0.95, 95% CI: 0.47-2.03). The DR TI is associated with higher odds of death and/or SNI compared with NICU TI, and may help identify higher risk infants. There was no association between the number of TI attempts and death and/or SNI. · Delivery room intubation correlates with morbidity.. · Less than 2 intubation attempts are not associated with IVH.. · Provider training reduces intubation attempts..

Retrospective evaluation of percutaneous tracheostomy cases performed by griggs method in intensive care unit

Aim: Tracheostomy is frequently performed after prolonged endotracheal intubation in intensive care units (ICU). Percutaneous tracheostomy (PT) is often preferred because it is a less invasive bedside aplicable procedure and the complication rate is lower. The aim of this study is to present our experience of PT interventions in ICU.Material and Methods: Between January 2016 and March 2019, patients who underwent PT by Griggs method were evaluated retrospectively. Age, gender, length of ICU stay, hospitalization diagnoses, timing for tracheostomy, complications related to the procedure and discharge / death status of the patients were recorded.Results: Eighty-nine patients were examined. The mean age of the patients was 59.4 ± 19.5 years, and the mean length of ICU stay was 80.3 ± 10.2 days. Tracheostomy was most commonly performed for neurological disorders. Duration of intubation was 20.3 ± 4.5 days. Complications developed in 8 patients (8.9%). The most common complication was minor bleeding (3.3%). Mortality developed in 59 patients (66.2%); 9 patients (10.1%) were discharged to the palliative service and 8 patients (8.9%) were discharged home. The mean length of ICU stay was 80.3 ± 10.2 days in tracheostomized patients, 56.4 ± 8.9 days in discharged patients and 92.5 ± 12.5 days in patients who died.Conclusion: In our study, performing day of tracheostomy was found to be higher. This may be due to patient relatives' ignorance of tracheostomy. By giving trainings to patients’ relatives, tracheostomy may be performed earlier and complications due to late performed tracheostomy can be prevented.

Center effect in intubation risk in critically ill immunocompromised patients with acute hypoxemic respiratory failure

BackgroundAcute respiratory failure is the leading reason for intensive care unit (ICU) admission in immunocompromised patients, and the need for invasive mechanical ventilation has become a major clinical endpoint in randomized controlled trials (RCTs). However, data are lacking on whether intubation is an objective criteria that is used unbiasedly across centers. This study explores how this outcome varies across ICUs.MethodsHierarchical models and permutation procedures for testing multiple random effects were applied on both data from an observational cohort (the TRIAL-OH study: 703 patients, 17 ICUs) and a randomized controlled trial (the HIGH trial: 776 patients, 31 ICUs) to characterize ICU variation in intubation risk across centers.ResultsThe crude intubation rate varied across ICUs from 29 to 80% in the observational cohort and from 0 to 86% in the RCT. This center effect on the mean ICU intubation rate was statistically significant, even after adjustment on individual patient characteristics (observational cohort: p value = 0.013, median OR 1.48 [1.30–1.72]; RCT: p value 0.004, median OR 1.51 [1.36–1.68]). Two ICU-level characteristics were associated with intubation risk (the annual rate of intubation procedure per center and the time from respiratory symptoms to ICU admission) and could partly explain this center effect. In the RCT that controlled for the use of high-flow oxygen therapy, we did not find significant variation in the effect of oxygenation strategy on intubation risk across centers, despite a significant variation in the need for invasive mechanical ventilation.ConclusionIntubation rates varied considerably among ICUs, even after adjustment on individual characteristics.

Effects of new type oral nursing on oral status among patients with orotracheal intubation in ICU

Objective To explore the effects of new type oral nursing on oral status among patients with orotracheal intubation in intensive care unit (ICU) . Methods Based on convenience sampling, we selected 51 patients with orotracheal intubation and mechanical ventilation in ICU at First People's Hospital of Shangqiu in control group from June 2017 to January 2018, and 55 patients in observation group from February 2018 to October 2018. Control group carried out traditional oral nursing, while observation group adopted the new type oral nursing which used Bass brushing method combined with scrubbing by gauze. Before and after intervention, we compared the score of Beck Oral Assessment Scale, score of halitosis and oral bleeding of patients between two groups. Results There were no statistical differences in the scores of Beck Oral Assessment Scale and halitosis of patients between two groups on admission in ICU (P>0.05) . One week after nursing, the scores of Beck Oral Assessment Scale and halitosis of patients in observation group were lower than those in control group with statistical differences (P 0.05) . Conclusions The new type oral nursing can improve oral status, halitosis and quality of oral nursing among ICU patients with orotracheal intubation. Key words: Intensive care units; Oral nursing; Tracheal intubation; Oral status

Nasal High-Flow Preoxygenation for Endotracheal Intubation in the Critically Ill Patient: A Randomized Clinical Trial

Background: Although performed daily, intubation in intensive care units (ICU) remains a critical procedure with life-threatening adverse events. High-flow therapy by nasal cannulae (HFNC) is now widespread in the operating room and in the ICU, especially for preoxygenation before intubation in non-hypoxemic patients. However, no large randomized study has assessed its relevance in this population. Methods: The PROTRACH study is a randomized, multicenter open-labelled, controlled trial, including non-severely hypoxemic patients requiring intubation in medical or surgical ICU. Patients were randomly allocated to receive 4-minute preoxygenation delivered by HFNC or standard high-flow face mask (HFFM) before intubation. HFNC was maintained throughout the intubation procedure whereas HFFM was removed to perform laryngoscopy. The primary outcome was the lowest pulse oximetry throughout the intubation procedure. Secondary outcomes included drop in pulse oximetry, adverse events related to intubation, and outcome in the ICU. Main Findings: A total of 192 patients were randomized. In the intent-to-treat analysis, 184 patients (HFNC n = 95; HFFM n = 89), the median [IQR] lowest pulse oximetry was 100% [97;100] for HFNC and 99 % [95;100] for the HFFM group (P = 0.30). Mild desaturation below 95% was more frequent with HFFM (23%) than with HFNC (12%) (relative risk 0.51, CI 95% [0.26 to 0.99], P = 0.045). There were fewer adverse events in the HFNC group (6%) than in the HFFM group (19%) (relative risk 0.31, CI 95% [0.13 to 0.76], P = 0.007), including significantly fewer severe adverse events, respectively 6 (6%) and 14 (16%) with HFNC and HFFM (relative risk 0.38, CI 95% [0.15 to 0.95], P = 0.03). There was no difference in the outcome in the ICU with a mortality rate of 27% in both groups (P = 0.90). Interpretation: Compared with HFFM, preoxygenation with HFNC in the ICU did not improve the lowest level of pulse oximetry during intubation in the non-severely hypoxemic patients but led to a reduction in severe and moderate intubation-related adverse events. Clinical Trial Number: Clinicaltrials.gov identifier: NCT02700321, Eudra CT: 2015-A00145-44 Funding Statement: The French Ministry of Health (Interregional French Clinical Hospital Research Program grant (PHRCi 2014 - API12/N/077), a grant for research & innovation missions (University Hospital of Nantes) and by Fisher & Paykel Healthcare. Declaration of Interests: Declaration of Interest: Christelle Volteau, Gwenael Colin, Adel Maamar, Vanessa Jean Michel, Pierre Joachim Mahe, Mickael Landais, Noelle Brule, Cedric Bretonniere, Olivier Zambon and Christophe Guitton declare no conflict of interest. Stephan Ehrmann declares receiving consultancy fees from Aerogen Ltd, La Diffusion Technique Francaise and Baxter healthcare and unrestricted research support from Fisher and Paykel, Aerogen Ltd and Hamilton medical. Mickael Vourc’h declares personal fees from MSD, Pfizer, Baxter, grants from Fisher Paykel, outside the submitted work. Ethics Approval Statement: Three methods of consent were available. When possible, capable patients were included after written informed consent. Most patients were included after the written informed consent of their next-of-kin or following an emergency inclusion procedure if not available at the time of inclusion. Then, consent was obtained from all patients as soon as possible after recovery. The appropriate ethics committee (Comite de Protection des Personnes, Rennes, France) approved this study protocol in September 2015 (15/13-975).

Comparison between Glidescope, Airtraq and Macintosh laryngoscopy for emergency endotracheal intubation in intensive care unit: Randomized controlled trial

BackgroundEmergency endotracheal intubation in intensive care is a major challenge that can be associated with life-threatening complications. The aim of this study was to evaluate the success of the first attempt of endotracheal intubation and incidence of complications using Macintosh laryngoscopy, Airtraq or Glidescope during emergency intubation in intensive care.Patients and methodsOne hundred twenty adult intensive care patients of ASA physical status III and IV who required emergency endotracheal intubation were randomly allocated into 3 groups. Group M (40 patients) were intubated using Macintosh laryngoscopy. Group G (40 patients) were intubated using Glidescope. Group A (40 patients) were intubated using Airtraq. The primary outcome was the success of the first attempt of endotracheal intubation. Secondary outcomes included the number of intubation attempts, duration of intubation, glottic view as assessed by Cormack-Lehane grade (C&L grade) and incidence of complications.ResultsSuccess of the first attempt of endotracheal intubation was significantly higher in both groups G and A compared to group M (p < 0.05). The number of intubation attempts was significantly higher in group M compared to both groups G and A (p < 0.05). The duration of endotracheal intubation was 28.80 ± 10.27 s in group M compared to 31.45 ± 12.17 s in group G and 32.25 ± 11.96 s in group A (p > 0.05). The C&L grade was significantly better in both groups G and A compared to group M (p < 0.05). No statistically significant difference between the three groups in HR or MAP. The incidence of oxygen desaturation was significantly more in group M compared to groups G and A. No statistically significant difference between the 3 studied groups regarding the incidence of other complications.ConclusionBoth Glidescope and Airtraq have higher first attempt success rate with a better glottic view and less incidence of oxygen desaturation than Macintosh laryngoscopy during emergency intubation in intensive care.

Preoxygenation with non-invasive ventilation versus high-flow nasal cannula oxygen therapy for intubation of patients with acute hypoxaemic respiratory failure in ICU: the prospective randomised controlled FLORALI-2 study protocol

IntroductionEndotracheal intubation in intensive care unit (ICU) is a procedure at high risk of life-threatening complications. Among them, severe oxygen desaturation, usually defined as a drop of pulse oxymetry (SpO2)...

Determinants of Endotracheal Intubation in Critically Ill Patients Undergoing Gastrointestinal Endoscopy Under Conscious Sedation.

Our primary aim was to determine the factors leading to prophylactic endotracheal intubation in intensive care unit (ICU) patients undergoing gastrointestinal endoscopy. Secondary aims were to determine the rate of unplanned endotracheal intubations during endoscopy and to determine the rate of aspiration following endoscopy for patients admitted to the ICU. Critically ill adult (≥18 years) patients who underwent upper and lower endoscopic procedures from January 2012 to July 2016 in a medical/surgical ICU were included. Determinants of prophylactic endotracheal intubation prior to endoscopy as well as other postprocedure outcomes were electronically captured by a validated data mart system. Given our focus on aspiration in those who were not endotracheally intubated prior to endoscopy, we used a validated definition a priori. A total of 320 patients were included in the final analysis: 76(24%) were intubated prior to endoscopy and 244 (76%) were not. The endotracheally intubated group had a significantly higher Acute Physiologic and Chronic Health Evaluation III (44.5 [16.2] vs 39.5 [15.5]; P = .02) and Sequential Organ Failure Assessment (6.9 [4.4] vs 3.8 [3]; P ≤ .01) scores, higher rate of hematemesis within 24 hours of endoscopy (28 [37%] vs 45 [18%]; P ≤ .01), and higher rate of upper endoscopy (72 [96%] vs 181 [74%]; P ≤ .01). We composed a composite outcome for multivariable analyses, which demonstrated the rate of any complication was significantly higher among those who were intubated prior to the procedure versus those who were not intubated previously (odds ratio: 2.80, 95% confidence interval (CI): 1.16-6.72, P = .02). Endoscopy performed in the ICU without endotracheal intubation is safe. However, patient selection for prophylactic intubation prior to endoscopy is of critical importance as illustrated in this study with higher illness severity, planned upper endoscopy, and hematemesis 24 hours prior being key factors on deciding to perform endotracheal intubation. Prophylactic intubation for endoscopy and preexisting cardiac disease were associated with a higher rate of adverse outcomes.