Endotracheale Intubation

Although several advantages are attributed to tracheotomy in ICU patients requiring mechanical ventilation (MV), true benefits and the optimal timing of tracheotomy remain controversial. In this study, we compared early tracheotomy (ET) with prolonged intubation (PI) in severely ill patients requiring prolonged MV. Prospective, randomized study. Twenty-five medical and surgical ICUs in France. Patients expected to require MV > 7 days. Patients were randomised to either (open or percutaneous) ET within 4 days or PI. The primary end-point was 28-day mortality. Secondary end-points were: the incidence of ICU-acquired pneumonia, number of d1-d28 ventilator-free days, time spent in the ICU, 60-day mortality, number of septic episodes, amount of sedation, comfort and laryngeal and tracheal complications. A sample size of 470 patients was considered necessary to obtain a reduction from 45 to 32% in 28-day mortality. After 30 months, 123 patients had been included (ET = 61, PI = 62) in 25 centres and the study was prematurely closed. All group characteristics were similar upon admission to ICU. No difference was found between the two groups for any of the primary or secondary end-points. Greater comfort was the sole benefit afforded by tracheotomy after subjective self-assessment by patients. The trial did not demonstrate any major benefit of tracheotomy in a general population of ICU patients, as suggested in a previous meta-analysis, but was underpowered to draw any firm conclusions. The potential advantage of ET may be restricted to selected groups of patients.

Assess the risk of complications during endotracheal intubation (ETI) and their association with the skill level of the intubating physician. Prospective cohort study of 136 patients intubated by the intensive care team during a 5-month period. Standardized data forms were used to collect detailed information on the intubating physicians, supervisors, techniques, medications and complications. Canadian academic intensive care unit. All intubations were successful and there were no deaths during intubation. Non-experts were supervised in 92% of procedures. Expert operators were successful within two attempts in 94%, compared to only 82% of non-experts (P = 0.03), with 13.2% of all intubations requiring > or =3 attempts. Furthermore, 10.3% of intubations required 10 or more minutes. Difficult intubation (3 or more attempts by an expert) occurred in 6.6%. Overall risk of complications was 39%, including: severe hypoxemia (19.1%), severe hypotension (9.6%), esophageal intubation (7.4%) and frank aspiration (5.9%). ICU and hospital mortality were 15.4 and 29.4%, respectively. Compared with non-expert intubating physicians, propensity score-adjusted odds ratios (95% confidence interval) for expert physicians were 0.92 (95% CI: 0.28, 3.05, P = 0.89) for any complication, 0.45 (95% CI: 0.09, 2.20, P = 0.32) for ICU mortality and 0.47 (95% CI: 0.13, 1.70, P = 0.25) for hospital mortality. Two or more attempts at ETI was independently associated with an increased risk of severe complications (OR 3.31, 95% CI: 1.30, 8.40, P = 0.01). These prospective data show a high risk of serious complications, and difficult intubations, that are associated with ETI of the critically ill. Artificial airways and complications.

The difficult airway is a common problem in adult critical care patients. However, the challenge is not just the establishment of a safe airway, but also maintaining that safety over days, weeks, or longer. This review considers the management of the difficult airway in the adult critical care environment. Central themes are the recognition of the potentially difficult airway and the necessary preparation for (and management of) difficult intubation and extubation. Problems associated with tracheostomy tubes and tube displacement are also discussed. All patients in critical care should initially be viewed as having a potentially difficult airway. They also have less physiological reserve than patients undergoing airway interventions in association with elective surgery. Making the critical care environment as conducive to difficult airway management as the operating room requires planning and teamwork. Extubation of the difficult airway should always be viewed as a potentially difficult reintubation. Tube displacement or obstruction should be strongly suspected in situations of new-onset difficult ventilation. Critical care physicians are presented with a significant number of difficult airway problems both during the insertion and removal of the airway. Critical care physicians need to be familiar with the difficult airway algorithms and have skill with relevant airway adjuncts.