INTUB study finds low use of capnography during tracheal intubation. This is disheartening. 

Two new studies suggest wide international variation in intubation and extubation practices and associated adverse events among critically ill patients receiving mechanical ventilation. 

“Variability can only be leveraged and addressed once its existence is laid bare for all to see. By doing so, these studies serve to advance current understanding of ways to improve care for critically ill patients,” Dr. Hayley Gershengorn of the University of Miami Miller School of Medicine in Florida writes in an editorial in JAMA, where both studies appear.

The INTUBE study team evaluated the incidence and nature of adverse peri-intubation events and assessed the current practice of intubation in 2,964 critically ill patients (median age, 63; 63% men) undergoing tracheal intubation across 197 sites in 29 countries.

“A key finding of this study was the identification of cardiovascular instability as the most frequent adverse event following intubation,” report first author Dr. Vincenzo Russotto of the University of Milano-Bicocca, in Italy, and colleagues.

The main reason for intubation in the cohort was respiratory failure (52%), followed by neurological impairment (31%) and cardiovascular instability (9.4%). Resident physicians intubated 52% of patients, and anesthesiologists intubated 54.0%.

Nearly two-thirds of patients (62%) received preoxygenation by a bag-valve mask; standard facemask was used in 13%, non-invasive ventilation in 12% and high-flow nasal cannula in 5%.

Sixty-two percent of patients underwent rapid-sequence induction (i.e., no ventilation between induction and laryngoscopy).

The investigators note that the role of video laryngoscopy to facilitate tracheal intubation in critically ill patients “remains unclear” and it was used in only 505 patients (17%).

While ketamine and etomidate have been recommended as the induction agent of choice for intubation of critically ill patients, they were seldom used, with propofol still representing the most commonly used induction agents, the team found.

Also noteworthy, say the researchers, was the low use of waveform capnography (35%) as standard monitoring during tracheal intubation. “In 68.9% of patients with tracheal tube accidentally placed in the esophagus, waveform capnography was not in place, so clinicians relied on inaccurate clinical signs such as auscultation or chest movement for detection of esophageal intubation,” Dr. Russotto and colleagues report.