Medicina Pulmonar e Respiratória

Pre-endoscopic Intubation for Airway Protection in Patients Undergoing Evaluation for Hematemesis – Experience in a Tertiary Care Center

Abstract

Allen Chao*, Tamana Ahmadi, Patrick Chan, Melissa Mert, Ding Li and Ahmet Baydur

Background: Pre-endoscopic endotracheal intubation is frequently performed during hematemesis, with the assumption that it will prevent aspiration and other cardiopulmonary complications. However, current literature reveals limited studies showing this benefit. Furthermore, guidelines for identifying patients who would most benefit from pre-endoscopic intubation are lacking. We hypothesize that pre-endoscopic intubation as associated with increased cardiopulmonary complications. Our study aimed to compare the frequency of cardiopulmonary complications between patients presenting with hematemesis who underwent pre-endoscopic intubation versus those who did not.

Methods: A retrospective analysis of patients who underwent esophagogastroduodenoscopy (EGD) for hematemesis between May 2015 and April 2018 was conducted. Patients were subdivided into those who underwent pre-endoscopic intubation and those who did not. The primary endpoint of “cardiopulmonary complications,” was defined as the occurrence of pneumonia, pulmonary edema, pneumothorax, hypoxemia, sedation induced hypotension, shock or cardiac arrest within 72 hours after endoscopy or intubation. Number of units of red blood cells (RBC) transfused prior to endoscopy was used as a surrogate for acuity of bleed. Appropriateness of intubation was assessed by documented reason for intubation. Intubations due to witnessed hematemesis and solely from gastroenterology request were defined as inappropriate reasons for intubation.

Results: Of 300 distinct patient encounters undergoing endoscopy, 66 (22.0%) were intubated prior to the procedure. Witnessed hematemesis was the most common indication for intubation prior to endoscopy (47.0%). Patients who underwent pre-endoscopic intubation were associated with higher acuity of illness as evidenced by validated scoring systems (SAPSII/AIMS65). Median units of blood transfused in the intubated group vs. non-intubated group were 2 and 0 (p<0.001), respectively. Cardiopulmonary complications in the intubated group were more prevalent than in the non-intubated group (27.3% vs. 1.3% respectively; p=<0.001). After adjusting for differences in SAPSII, AIMS65, and pRBC, patients who were intubated had 15.36 (95% CI: 4.52-65.67) times the odds of having a complication than those who were not intubated (p<0.001). Furthermore, there were no significant differences in the proportion of complications in appropriate vs. inappropriate intubations (33.3% vs. 25.9%; p=0.72 by Fisher’s exact test).

Conclusion: Our study demonstrates that pre-endoscopic intubation in the setting of hematemesis can be associated with increased cardiopulmonary complications. When controlling for potential confounders including severity score, bleeding risk score, and acuity of bleed, this finding persisted. We also note that patients who are intubated have similar risk of complications, regardless of reason for intubation. Thus, this suggests that intubations prior to endoscopy should be performed cautiously and only in specific scenarios.