GCS of 8… But Should You Intubate?

January 26, 2024

Written by Clark Strunk

Spoon Feed
In patients with suspected acute poisoning who are comatose, a more restrictive intubation approach where intubation is withheld unless an accompanying emergent indication is present, may lead to fewer ICU admissions, decreased ICU length of stay, and decreased requirement for mechanical ventilation, with fewer adverse events.

But we must protect the airway…
Airway protection is one of the frequently regarded indications for intubation, with the rationale that comatose patients often experience a decline in some of their protective airway reflexes, and intubation may protect from aspiration. However, there is no high-quality evidence to guide this practice, and it remains unknown if the possible benefit of airway protection outweighs the procedural risks of intubation and the deleterious effects and complications of mechanical ventilation with positive pressure ventilation.

This was a multicenter, unblinded, RCT of 225 patients with suspected ingestion leading to decreased level of consciousness (GCS < 9) randomized to a restrictive intubation strategy versus control (intubation at the discretion of the treating physician). In the restrictive group, intubation was withheld unless patients developed respiratory compromise, shock, seizure, or vomiting. 21 (18.1%) patients in the restrictive group required intubation versus 65 (59.6%) patients in the control group: OR 0.12 (95%CI 0.06-0.24). The restrictive group also had fewer ICU admissions, OR 0.23 (0.12-0.44); reduced median ICU LOS, RR 0.39 (0.24-0.66); reduced median hospital LOS, RR 0.74 (0.53-1.03); and fewer adverse events (6% vs. 14.7%).

How will this change my practice?
Ultimately, my decision to intubate a patient will remain based on my clinical assessment and integration of multiple factors including a patient’s ability to oxygenate and ventilate, their underlying acute illness, projected clinical course, as well as their ability to protect their airway. However, based on the results of this study, I will likely begin to implement a more restrictive intubation approach in select patients with an isolated indication of decreased level of arousal, especially in the context of disease processes with anticipated short duration or which are readily reversible, as is the case with many acutely poisoned patients.

Source
Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023 Dec 19;330(23):2267-2274. doi: 10.1001/jama.2023.24391.