International study conducted at Cabrini highlights the complications of intubating critically ill patients

Date: 16/04/2021

A study published last month in JAMA shows more than 40 per cent of critically ill patients suffer a life threatening complication when being intubated.

Tracheal intubation is a high risk procedure commonly performed in critically ill patients who are suffering from severe respiratory problems requiring support to breathe. The new study findings highlight just how significant the risks are with intubating critically ill patients.

The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE), was conducted to gain a better understanding of the complications experienced by critically ill patients undergoing intubation in intensive care units (ICUs), emergency departments, and wards from October 1, 2018 to July 31, 2019. INTUBE is the largest study of intubations in critically ill patients ever conducted, and included 2964 patients from 197 sites in 29 countries across five continents.

Cabrini researcher Associate Professor David Brewster, Deputy Director of Intensive Care at Cabrini Health, and the Clinical Dean for the Monash University Clinical School, was a co-author and the national coordinator for the INTUBE study in Australia and New Zealand.

A/Prof Brewster said the study shed light on the “significant morbidity and mortality risk associated with intubation in the critically ill as well as patient and operator factors associated with worse outcomes”.

“This is a major achievement” A/Prof Brewster said. “To have such a large international collaboration of researchers successfully creating this database shows that research on such a large scale is possible within the ICU community with regards to airway management. It is by far the largest study ever conducted on intubation outcomes and the first true multi-national study in this area.

“We found major peri-intubation events occurred in a higher percentage of patients who later died in ICU (versus ICU survivors). This means that relevant outcomes were identified. Major peri-intubation events were more frequent in patients who required multiple intubation attempts. Worse outcomes for patients were less common amongst skilled and experienced operators and less common with the use of videolaryngoscopy. This showed the outcomes are modifiable.”

A/Prof Brewster said on a personal level, it was fantastic to be able to lead such a large trial in Australia and New Zealand.

“The support of the Australian and New Zealand Intensive Care Society (ANZICS) was crucial in recruiting sites and the ability to manage our national dataset from the Cabrini ICU was only possible given the hard work of our ICU research coordinator, Shannon Simpson”, he said.

Key findings from the INTUBE study included:

  • The main reason for intubation was respiratory failure in 52.3 per cent of patients, followed by neurological impairment in 30.5 per cent, and cardiovascular instability in 9.4 per cent.
  • More than 45 per cent of patients experienced at least one life threatening complication during intubation.
  • The most common complications following tracheal intubation was cardiovascular instability, experienced by 1172 patients (42.6 per cent), severe hypoxemia in 272 patients (9.3 per cent) and cardiac arrest in 93 patients (3.1 per cent).
  • Overall ICU mortality was 32.8 per cent (966 patients).
  • Patients who experienced a complication due to intubation were more likely to die (40.7 per cent) than those who did not experience a complication (26.3 per cent). 
  • First pass intubation success was achieved for 2360 patients (79.8 per cent). A second attempted intubation was achieved for 460 patients (15.6 per cent). More than two attempts at intubation was required for 133 patients (4.5 per cent). The rate of complications was significantly lower with first pass intubation success than it was for patients requiring two attempts and for patients requiring three or more attempts.