Intubations in the ICU are more likely to be difficult than intubations in theatre. A recent study in Anesthesia and Intensive Care gives us an estimate of how often this happens. The researchers evaluated 198 patients who were intubated in the ICU by anaesthetists. Data was gathered using anonymous questionnaires filled out by the intubating anaesthetist.

23% of intubations were considered ‘difficult’. This is somewhat consistent with the few other studies who estimate the percentage of difficult intubations in critically ill to be in the range of 6-28%. That’s a lot. Even more worrying, in this study, is how only 25% of the difficult intubations were predicted to be difficult before intubation.

Also, in more than 50% of the patients who proved difficult to intubate, the intubation was performed as an emergency measure.

As always it is hard to compare studies like this to one’s own practice due to differing protocols, local tradition and what not. (For example, in the study 10% of intubations were blind nasals which is a very rare thing to do in the part of the world I work in.)

The study mentions the doctor’s qualifications, but doesn’t mention the rest of the team’s qualifications. I know I have often taken along an OR anaesthetic nurse to the ICU if I get called for an ICU intubation. Not that ICU nurses are bad at airway management, but the anaesthetic nurses have a lot more daily exposure and experience with intubations and the flow of that procedure.

In addition to this group being critically ill, marginal patients, my take is that this has to do with environment and management. Taken out of the safe and well-known surroundings of your OR, and possibly stripped of your anaesthetic nurse with airway management skills, the environment in the ICU might feel uncomfortable, and you might not do the usual preparations as you would in your OR. You need to control your environment. Take your time with the preparations. Get the proper assistance.

Anaesth Intensive Care. 2012 Jan;40(1):120-7. ‘Incidence of difficult intubation in intensive care patients: analysis of contributing factors.’ Heuer, Barwing, Russo…

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