Prophylactic endotracheal intubation (PEI) prior to endoscopy for upper GI bleeding in critically ill adults may actually increase, rather than decrease, the risk of unplanned cardiopulmonary events, according to results of a retrospective cohort study.
In particular, the study showed a significant increase in risk of patients developing pneumonia, according to study author Umar Hayat, MD, Medicine Institute, Cleveland Clinic, and colleagues.
“The practice of PEI could carry significant risks and might be a factor that leads to this dreaded outcome [pneumonia] in patients presenting with upper GI bleeding, instead of preventing it,” Dr. Hayat and colleagues wrote (Gastrointest Endosc. 2017;86:500-9. doi:10.1016/j.gie.2016.12.008).
The role of PEI in mitigating risk of cardiopulmonary adverse events remains controversial for patients presenting with upper GI bleeding, who can have mortality rates as high as 10% for nonvariceal bleeds and 20% for variceal causes, the investigators said.
Dr. Hayat and colleagues reviewed data for a total of 365 patients who had brisk upper GI bleeding, of whom 144 (39.5%) underwent PEI prior to esophagogastroduodenoscopy (EGD). The average patient age was 59 years, and 64% were male.
The composite primary endpoint of the study, cardiopulmonary unplanned events, was defined as occurrence of pneumonia, pulmonary edema, acute respiratory distress syndrome, shock/hypotension, arrhythmia, myocardial infarction, or cardiac arrest within 48 hours of EGD.
The final analysis included 200 intubated and nonintubated patients matched on a 1:1 basis using propensity score matching.
The researchers found that post-EGD adverse outcomes were more common in patients who had undergone PEI prior to EGD (odds ratio, 3.8; 95% confidence interval, 1.4-10.2), published data show. The rate of unplanned cardiopulmonary events was 20% for intubated patients, compared with 6% for nonintubated patients (P = .008).
Even after adjusting for the presence of esophageal varices, the difference remained significant, Dr. Hayat and colleagues wrote.
Pneumonia in particular was significantly more common in the PEI group: published data show 14% of patients who underwent PEI had pneumonia within 48 hours of EGD, compared with 2% of nonintubated patients (P = .01).
Rates of shock within 48 hours of EGD were also higher in the PEI group (14% vs. 6%), though the finding did not reach statistical significance, the authors added.
Currently, PEI is “variably used” in clinical practice, the authors wrote, and factors that may play into the decision to utilize this strategy include bleeding severity and ongoing hematemesis, among other factors. In survey data cited by Dr. Hayat and associates, 58% of experts said they would consider intubation for patients with ongoing hematemesis, and about one-quarter said they would intubate if they suspected hemodynamic compromise.
Although future prospective, controlled studies are needed to confirm these findings, the authors did advise caution in selecting patients for PEI in critically ill patients presenting with upper GI bleeding.
“The benefits and risks of intubation should be carefully weighed when considering airway protection before an EGD in this group of patients,” they wrote.
The invesigators disclosed no financial relationships relevant to the current study.
