Variation in Intubation and Extubation Practices

Intubation is a staple in critical care and, especially in the midst of a respiratory pandemic, has unfortunately become more common than ever. However, there is much variation in intubation practices globally, regionally, and institutionally². This is partially a good thing; practices should be adjusted to best suit the needs of the patient². However, other sources of variability, such as local culture, pharmaceutical influence, access to resources or systemic inequities can lead to suboptimal care and meaningful differences in patient outcomes.

There have been two international studies looking at the effects of such variation, the first of which was a study looking at peri-intubation adverse events in seriously ill patients in 197 clinical sites across 29 different countries³. Such adverse events included metabolic acidosis, shock, hemodynamic instability, hypoxemia and respiratory failure, and these events are more common in critical patients than patients undergoing routine intubation in the OR³. The incidence and consequences of such events had never prior been studied internationally, but a UK audit in 2011 showed that gaps in clinical practice caused by inconsistent identification of at-risk patients, poor planning, scheduling issues with skilled physicians, lack of available equipment, and incorrect/failed interpretations of capnography were highly related to morbidity and mortality³. This study focused on cardiovascular instability post-intubation, which is the most common adverse event to occur following intubation, and found that multiple intubation attempts was a major predictor of cardiovascular instability³. Since skilled clinicians achieve first-pass intubation significantly more often than residents or clinical students, clinical sites need to either increase availability of such skilled practitioners, or make sure all trainees are well-trained and experienced in the practice of intubation³. Moreover, this point goes to show that non-patient-related variation in intubation can cause a significant change in patient outcomes³.

The second study looked at extubation practices after mechanical ventilation, also in critically ill patients¹. This study similarly spawned from a lack of literature concerning discontinuation practices for patients on a mechanical ventilator, despite the fact that ventilation is a fairly common clinical practice¹. There was significant regional variation in weaning protocols and frequency of screening for spontaneous breathing trials across clinical centers¹. SBTs were associated with higher morbidity and mortality, and longer ICU stays when compared with direct extubation¹. Furthermore, patients with a failed daily screen, with or without SBT, were more likely to need invasive mechanical ventilation for more than three weeks and less likely to be successfully extubated and survive until discharge¹. A post-hoc analysis showed that level of sedation was a major indicator of failing the initial SBT test, and since regional centers vary significantly in sedation and weaning protocols, this study suggests that such variation can affect morbidity and mortality¹.

Intubation and subsequent extubation is a common clinical practice, and having a streamlined, standardized protocol that informs clinicians about best practices with these procedures would be beneficial.

References

1. Burns KEA, Rizvi L, Cook DJ, Lebovic G, Dodek P, Villar J, Slutsky AS, Jones A, Kapadia FN, Gattas DJ, Epstein SK, Pelosi P, Kefala K, Meade MO. Ventilator Weaning and Discontinuation Practices for Critically Ill Patients. Journal of the American Medical Associations, 2021; 325(12): 1173-1184. doi: 10.1001/jama.2021.2384
2. Gershengron HB. International Variation in Intubation and Extubation Practices and Adverse Events Among Critically Ill Patients Receiving Mechanical Ventilation. Journal of the American Medical Association, 2021; 325(12): 1157-1159. doi: 10.1001/jama.2021.1178
3. Russotto V, Myatra SN, Laffey JG et al. Intubation Practices and Adverse Peri-intubation Events in Critically-Ill Patients From 29 Countries. Journal of the American Medical Association, 2021; 325(12): 1164-1172. doi: 10.1001/jama.2021.1727