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- Title
Early identification of patients at risk for difficult intubation in the intensive care unit.
- Authors
De Jong, Audrey; Molinari, Nicolas; Terzi, Nicolas; Mongardon, Nicolas; Arnal, Jean-Michel; Guitton, Christophe; Allaouchiche, Bernard; Paugam-Burtz, Catherine; Constantin, Jean-Michel; Lefrant, Jean-Yves; Leone, Marc; Papazian, Laurent; Asehnoune, Karim; Maziers, Nicolas; Azoulay, Elie; Pradel, Gael; Jung, Boris; Jaber, Samir; AzuRéa Network for the Frida-Réa Study Group
- Abstract
Rationale: Difficult intubation in the intensive care unit (ICU) is a challenging issue. Objectives: To develop and validate a simplified score for identifying patients with difficult intubation in the ICU and to report related complications. Methods: Data collected in a prospective multicenter study from 1,000 consecutive intubations from 42 ICUs were used to develop a simplified score of difficult intubation, which was then validated externally in 400 consecutive intubation procedures from 18 other ICUs and internally by bootstrap on 1,000 iterations. Measurements and Main Results: In multivariate analysis, the main predictors of difficult intubation (incidence = 11.3%) were related to patient (Mallampati score III or IV, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening); pathology (severe hypoxia, coma); and operator (nonanesthesiologist). From the [beta] parameter, a seven-item simplified score (MACOCHA score) was built, with an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.85-0.94). In the validation cohort (prevalence of difficult intubation = 8%), the AUC was 0.86 (95% CI, 0.76-0.96), with a sensitivity of 73%, a specificity of 89%, a negative predictive value of 98%, and a positive predictive value of 36%. After internal validation by bootstrap, the AUC was 0.89 (95% CI, 0.86-0.93). Severe life-threatening events (severe hypoxia, collapse, cardiac arrest, or death) occurred in 38% of the 1,000 cases. Patients with difficult intubation (n = 113) had significantly higher severe life-threatening complications than those who had a nondifficult intubation (51% vs. 36%; P < 0.0001). Conclusions: Difficult intubation in the ICU is strongly associated with severe life-threatening complications. A simple score including seven clinical items discriminates difficult and nondifficult intubation in the ICU. Clinical trial registered with www.clinicaltrials.gov (NCT 01532063).
- Publication
American Journal of Respiratory & Critical Care Medicine, 2013, Vol 187, Issue 8, p832
- ISSN
1073-449X
- Publication type
Journal Article
- DOI
10.1164/rccm.201210-1851OC