Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients.pdf

To the Editor We have several comments about the recent study describing intubation practices and peri-intubation events in critically ill patients from 29 countries. First, previous studies concerning peri-intubation morbidity in critically ill patients have demonstrated that early identification and strategic management by skilled and experienced clinicians can save lives. Although it is reassuring that fewer adverse events were reported in this study when patients underwent intubation by attending physicians, the lesson learned from the UK’s National Emergency Laparotomy audit and from the Emergency Anesthesia Services Guidelines that followed is that critically ill patients requiring intubation deserve attending-level care. Sadly, this lesson has not been widely operationalized, as resident physicians were responsible for intubating 52% of the patients in this study. More information regarding resident experience level, their intubation skills, and the immediate availability of senior level backup would be of interest.

致编辑 我们对最近的一项研究发表了一些评论，该研究描述了来自 29 个国家的危重患者的插管实践和围插管事件。首先，之前关于危重患者气管插管期间发病率的研究表明，熟练和经验丰富的临床医生的早期识别和战略管理可以挽救生命。虽然令人欣慰的是，当患者接受主治医师插管时，本研究中报告的不良事件较少，但从英国国家紧急剖腹手术审核和随后的紧急麻醉服务指南中吸取的教训是，需要插管的危重患者值得就诊——水平护理。遗憾的是，这一课程并未得到广泛应用，因为在本研究中，住院医师负责为 52% 的患者插管。有关居民经验水平、他们的插管技能以及高级备份的即时可用性的更多信息将是令人感兴趣的。

Second, we disagree that the role of video laryngoscopy remains unclear. What is clear is that video laryngoscopy, like any tool used to facilitate tracheal intubation, requires proficiency to achieve successful intubation. Third, we believe that the identification of specific risk factors should inform clinical management when caring for critically ill patients who require high-risk interventions. In this study, intubation itself was unlikely to be the cause of cardiovascular instability, which developed in 42.5% of patients. Instead, the administration of propofol, a sympatholytic induction agent that can cause hypotension, was used in 41.5% of patients and likely precipitated cardiovascular instability. Use of vasopressors to mitigate the predictable effects of sympatholytic induction agents is critical to the management of patients at high risk of hypotension due to impaired physiological reserve.

其次，我们不同意视频喉镜检查的作用尚不清楚。显而易见的是，视频喉镜检查与用于促进气管插管的任何工具一样，需要熟练掌握才能成功插管。第三，我们认为，在护理需要高风险干预的危重患者时，特定危险因素的识别应为临床管理提供信息。在这项研究中，插管本身不太可能是导致 42.5% 患者发生心血管不稳定的原因。相反，41.5% 的患者使用丙泊酚（一种可引起低血压的交感神经诱导剂）并可能导致心血管不稳定。使用血管加压药来减轻交感神经诱导剂的可预测影响对于因生理储备受损而处于低血压高风险的患者的管理至关重要。

Fourth, although the vehicle for preoxygenation was described, this study did not provide information about the method for achieving alveolar denitrogenation.Moreover, even though rapid sequence induction was performed in 62% of patients, the use of succinylcholine and rocuronium to facilitate rapid intubationwas low,whichmay enhance trauma to the oropharynx. Information about paralytic dosing would also be of interest. In addition, this study documented woeful underutilization ofwaveform capnography (used in 25% of patients) and colorimetric CO2 detection (used in 7.5% of patients), both of which should be considered the standard of care.

第四，虽然描述了预给氧的载体，但本研究没有提供有关实现肺泡脱氮的方法的信息。此外，即使在 62% 的患者中进行了快速序列诱导，使用琥珀胆碱和罗库溴铵来促进快速插管的情况很少 ，这可能会增加对口咽部的创伤。关于麻痹剂量的信息也很有趣。此外，该研究记录了波形二氧化碳图（用于 25% 的患者）和比色 CO2 检测（用于 7.5% 的患者）的严重利用率不足，这两者都应被视为护理标准。

Airwaymanagement in critically ill patients requires a plan, highly experienced clinicians, wise choice of pharmacologic options, facility with airway equipment, and a system that focuses on confirmation of correct tracheal intubation to minimize morbidity and mortality.

危重患者的气道管理需要一个计划、经验丰富的临床医生、明智的药物选择选择、配备气道设备的设施以及一个专注于确认正确气管插管以最大程度降低发病率和死亡率的系统。

To the EditorIn their recent study about the incidence and nature of adverse peri-intubation events in critically ill patients from 29 countries, Dr Russotto and colleagues reported that 45.2% of patients experienced at least 1 major adverse periintubation event, such as cardiovascular instability and severe hypoxia, and 3.1% had a cardiac arrest.

致编辑 在他们最近关于来自 29 个国家的危重患者中不良围插管事件的发生率和性质的研究中，鲁索托博士及其同事报告说，45.2% 的患者经历了至少 1 次主要的围插管不良事件，例如心血管不稳定和严重缺氧，3.1% 有心脏骤停。

We believe the authors omitted an important discussion about the possible adverse effects of rapid sequence induction, which was used in 62.2% of patients in this study. It is well-known that rapid sequence induction can greatly contribute to hemodynamic and respiratory collapse in such critically ill patients due to simultaneous infusion with general anesthetics and neuromuscular blocking agents.

我们相信作者省略了关于快速序列诱导可能产生的不良反应的重要讨论，在本研究中，62.2% 的患者使用了快速序列诱导。众所周知，由于同时输注全身麻醉剂和神经肌肉阻滞剂，快速序列诱导可以极大地促进此类危重患者的血流动力学和呼吸衰竭。

In addition, awake tracheal intubation may be a helpful alternative airway management procedure for critically ill patients. Although it requires a skilled anesthesiologist and patient cooperation, awake tracheal intubation can be safely achieved without use of neuromuscular blocking agents and requires less sedative medication. Recent consensus strongly supports the use of awake tracheal intubation for patients at high risk of hypoxemia to maintain spontaneous breathing.

此外，清醒气管插管可能是对危重患者有用的替代气道管理程序。虽然它需要熟练的麻醉师和患者的合作，但无需使用神经肌肉阻滞剂即可安全地实现清醒气管插管，并且需要较少的镇静药物。最近的共识强烈支持对低氧血症高危患者使用清醒气管插管以维持自主呼吸。

In Reply We agree with Drs Bloomstone and Eckhardt that operator skill may play a major role in the success of tracheal intubation and in patient outcomes peri-intubation. In our large international cohort, the first attempt at tracheal intubation was performed by a resident physician in 52% of cases. Fiftyfour percent of these residents were training in anesthesia and were typically performing 2 to 5 intubations per week.We also collected information on the total number of physicians skilled in performing intubation who were immediately available during the procedure. In 53% of intubations, only 1 skilled physician was present, while 2 to 3 skilled physicians were present in 40% of cases. After a first unsuccessful intubation attempt, in 57% of cases, an attending physician performed a successful intubation.

在回复中 我们同意布卢姆斯通和埃克哈特博士的观点，即操作者的技能可能在气管插管的成功和患者在插管期间的结果中发挥重要作用。在我们的大型国际队列中，52% 的病例首次尝试气管插管是由住院医师进行的。这些住院医师中有 54% 接受过麻醉培训，通常每周进行 2 到 5 次插管。我们还收集了有关在手术过程中立即可用的熟练插管医生总数的信息。 在 53% 的插管中，只有 1 名熟练的医生在场，而在 40% 的病例中，有 2 至 3 名熟练的医生在场。在第一次尝试插管失败后，在 57% 的病例中，主治医师成功地进行了插管。

We concur with Bloomstone and Eckhardt that video laryngoscopy is a powerful tool for airway management of critically ill patients because it provides improved visualization of the glottis and allows the opportunity for direct expert supervision of the procedure.However, in a recently published metaanalysis of randomized trials, video laryngoscopy did not increase first-attempt intubation success or improve patient outcomes in the intensive care unit. We agree that specific training in video laryngoscopy is critical and we support the goal of having a video laryngoscope available in every intensive care unit. However, additional evidence is required before the systematic use of video laryngoscopy can be recommended for all critically ill patients undergoing intubation.

我们同意布卢姆斯通和埃克哈特的观点，即视频喉镜检查是危重患者气道管理的强大工具，因为它可以改善声门的可视化，并允许专家直接监督手术过程。然而，在最近发表的随机试验荟萃分析中 ，视频喉镜检查并没有增加首次尝试插管的成功率或改善重症监护病房的患者预后。我们同意视频喉镜的特定培训至关重要，我们支持在每个重症监护病房都有视频喉镜的目标。然而，在推荐所有接受插管的危重患者系统地使用视频喉镜之前，还需要额外的证据。

The observational nature of our study prevented us from making practice-changing recommendations. The high incidence of major peri-intubation adverse events may have been influenced by the bundle of peri-intubation interventions, including the selection of induction agents. In a post hoc multivariable analysis, propofol was not significantly associated with the primary outcome of major adverse peri-intubation events. However, we cannot exclude a negative effect of propofol in patients with underlying hemodynamic instability. We did not observe an association with use of muscle relaxants and major adverse peri-intubation events.

我们研究的观察性质使我们无法提出改变实践的建议。主要围插管不良事件的高发生率可能受到围插管干预措施的影响，包括诱导剂的选择。在事后多变量分析中，丙泊酚与主要不良围插管事件的主要结果没有显着相关性。然而，我们不能排除丙泊酚对潜在血流动力学不稳定患者的负面影响。我们没有观察到与使用肌肉松弛剂和主要不良气管插管事件之间的关联。

In regard to the comments by Dr Masuda and colleagues about awake intubation in critically ill patients, we agree that coadministration of induction agents and muscle relaxants, along with the abolishment of spontaneous ventilation during positive-pressure ventilation, may contribute to periintubation hemodynamic instability, severe hypoxia, and cardiac arrest. Although mentioned as an option by international guidelines, awake intubation has several practical limitations in critically ill patients. Factors such as the urgency of the procedure, potential for limited patient cooperation, and presence of secretions and blood can make fiberoptic intubation a challenging procedure for even the most highly skilled physicians. Rapid sequence induction, currently considered standard procedure in critically ill patients, was used in 62% of patients undergoing intubation in our large international cohort. We agree that strategies to minimize major periintubation adverse events should have a high priority for research in critical care.

关于 Masuda 博士及其同事关于危重患者清醒插管的评论，我们同意诱导剂和肌肉松弛剂的共同给药，以及在正压通气期间取消自主通气，可能会导致围插管血流动力学不稳定，严重缺氧，心脏骤停。尽管国际指南将其作为一种选择，清醒插管在危重患者中存在一些实际限制。诸如手术的紧迫性、患者合作有限的可能性以及分泌物和血液的存在等因素可能使纤维插管术对于即使是最熟练的医生也是一项具有挑战性的手术。在我们的大型国际队列中，62% 的接受插管的患者使用了快速序列诱导，目前被认为是危重患者的标准程序。我们同意，在重症监护研究中，应优先考虑减少主要围插管不良事件的策略。