TOPLINE:
In comatose patients with a suspicion of acute poisoning, opting for a conservative approach by refraining from intubation has a significant clinical advantage concerning the combined outcomes of in-hospital mortality, duration of intensive care unit (ICU) stay, and length of hospital stay.
METHODOLOGY:
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This multicenter randomized trial conducted in 20 emergency departments (EDs) and 1 ICU in France included comatose patients with suspected acute poisoning.
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225 patients were randomly assigned to either a conservative strategy of withholding intubation or a routine practice where the decision for intubation is at the physician’s discretion.
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Each patient comparison resulted in a hierarchical definition of win, loss, or tie based on their respective outcomes.
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The primary outcome was a hierarchical composite end point of in-hospital death, duration of ICU stay, and length of hospital stay.
TAKEAWAY:
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No deaths were reported in either group.
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The conservative strategy of withholding intubation significantly improved the composite primary end point, with a win ratio of 1.85 (P < .001).
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The conservative approach also led to a lower rate of ICU admissions (absolute risk difference, −29.2 percentage points).
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Patients in the conservative strategy group experienced:
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Fewer adverse events from intubation (absolute risk difference, −8.6 percentage points).
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Lower rates of pneumonia after intubation (absolute risk difference, −7.8 percentage points).
IN PRACTICE:
The authors wrote that these findings may fill a gap in the existing literature which suggested that intubating patients for airway protection to limit the risk of aspiration pneumonia may in fact increase the risk of pneumonia.
SOURCE:
The study, with first author Yonathan Freund, was published online on November 29 in the JAMA .
LIMITATIONS:
Lack of blinding was a limitation of this trial. Also, some patients were intubated in the ED or the ICU and not the prehospital setting.
DISCLOSURES:
The study was funded by a grant from the French Ministry of Health. One author declared receiving personal fees from Ablative Solutions, Air Liquide, AstraZeneca, Sanofi, Servier, Novartis, and 4Living Biotech.
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