Peri-intubation complications in critically ill obese patients: a secondary analysis of the international INTUBE cohort
Vincenzo Russotto, John G. Laffey, Elena Tassistro, Sheila Nainan Myatra, Emanuele Rezoagli, Giuseppe Foti, Laura Antolini, Maria Grazia Valsecchi, Philippe R. Bauer, Konstanty Szułdrzyński, Luigi Camporota, Robert Greif, A. Higgs, Matteo Parotto, Roberto Fumagalli, Massimiliano Sorbello, Chiara Robba, Giacomo Grasselli, Giacomo Bellani, Pietro Caironi, Jean-Baptiste Lascarrou, the INTUBE Study Investigators, Matthew Anstey, Sandra Colica, David Brewster, Shannon Simpson, Adrian Regli, Ross O’Grady, Edward Litton, Janet Ferrier, Roland Bartholdy, Alexis Tabah, David Bowen, Rebecca Rowley, Jonathan Gatward, Julio Alonso, Sneha Varkey, Vijayanand Palaniswamy, Timothy Chimunda, Syed T. Reza, Mozaffer Hossain, Motiul Islam, Tarikul Hamid, Samareh Ajami, Andrew Steel, Lorenzo Sorbo, Alberto Goffi, Ian Randall, Neill K. J. Adhikari, Tasneem H. Mehesry, Maria M. Vera, Guillermo Bugedo, Gonzalo Labarca, Monica Silva, Wuhua Ma, Yongxing Li, Jiayan Wu, Lun Wu, Marijana Matas, Višnja Ivančan, Mario Pavlek, Slobodan Mihaljević, Aleksandra Jumić, Mate Moguš, Iva Tucić, Pavel Michalek, Marek Flaksa, Hernan Aguirre-Bermeo, Hugo Tirape-Castro, Maria F. Aguilera García, Diana Alvarez Montenegro, Diego Morocho Tutillo, Jose A. León Tutillo, Hadrien Winiszewski, Gael Piton, Nadia Aissaoui, Jean-Loup Augy, Benoit Champigneulle, Diane Zlotnik, Grégoire Muller, Sophie Jacquier, Sami Hraiech, Christophe Guervilly, Gaetan Plantefeve, Damien Contou, Jean Damien Ricard, Sebastien Besset, Gwenhael Colin, Caroline Pouplet, Adrien Mirouse, Elie Azoulay, Florence Boissier, Jean-Pierre Frat, Emmanuelle Mercier, Charlotte Salmon-Gandonnière, Maelle Martin, Alexis Ferre, Stephane Legriel, Cedric Bruel, Francois Philippard
Abstract
Airway management in critically ill obese patients is potentially associated with a higher risk of adverse events due to a constellation of physiological and anatomical challenges. Data from international prospective studies on peri-intubation adverse events in obese critically ill patients are lacking. INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was an international multicentre prospective cohort study enrolling critically ill adult patients undergoing in-hospital tracheal intubation in 197 sites from 29 countries worldwide from October 1, 2018, to July 31, 2019. This secondary analysis compares airway management practices and outcomes between obese (body mass index–BMI $$\ge$$ 30 kg/m2) and non-obese patients (BMI $$<$$ 30 kg/m2). A total of 2946 patients met inclusion criteria for this secondary analysis, 639 (21.7%) obese and 2307 (78.3%) non-obese. Severe peri-intubation hypoxemia was more frequently reported in obese compared to non-obese patients (12.1% vs 8.6% respectively, p = 0.01). Variables independently associated with a higher risk of peri-intubation hypoxemia were baseline SpO2/FiO2 (OR 0.996, 95% CI 0.994–0.997), 30–45° head-up position (OR 1.53, 95% CI 1.04–2.26) and first-pass intubation failure (OR for first-pass success 0.21, 95% CI 0.15–0.29). Obesity (OR 0.71, 95% CI 0.56–0.91) and 20° head-up position (OR 0.67, 95% CI 0.47–0.95) were independently associated with higher likelihood of first-pass intubation failure. In contrast, intubation by staff physician/consultant (OR 1.70, 95% CI 1.30–2.21) or anesthesiologists (OR 1.98, 95% CI 1.55–2.53) were associated with higher first-pass success. Compared to non-obese patients, obese critically ill exhibit a higher incidence of peri-intubation severe hypoxemia. In this population, worse baseline oxygenation and first-pass intubation failure significantly increase the risk of peri-intubation severe hypoxemia. As obesity is linked to a higher likelihood of first-pass intubation failure, likely driven by more challenging airway features, in this high-risk population first attempt should be performed by an expert operator to minimize peri-intubation complications. Trial registration: Clinicaltrials.gov NCT03616054 . Registered 3 August 2018.