An International Factorial Vignette-Based Survey of Intubation Decisions in Acute Hypoxemic Respiratory Failure - Yarnell, C. J.; Paranthaman, A.; Reardon, P.; Angriman, F.; Bassi, T.; Bellani, G.; Brochard, L.; De Grooth, H. J.; Dragoi, L.; Gaus, S.; Glover, P.; Goligher, E. C.; et al. (Crit Care Med, 2024)
OBJECTIVES: Intubation is a common procedure in acute hypoxemic respiratory failure (AHRF), with minimal evidence to guide decision-making. We conducted a survey of when to intubate patients with AHRF to measure the influence of clinical variables on intubation decision-making and quantify variability. DESIGN: Factorial vignette-based survey asking "Would you recommend intubation?" Respondents selected an ordinal recommendation from a 5-point scale ranging from "Definite no" to "Definite yes" for up to ten randomly allocated vignettes. We used Bayesian proportional odds modeling, with clustering by individual, country, and region, to calculate mean odds ratios (ORs) with 95% credible intervals (CrIs). SETTING: Anonymous web-based survey. SUBJECTS: Clinicians involved in the decision to intubate. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Between September 2023 and January 2024, 2,294 respondents entered 17,235 vignette responses in 74 countries (most common: Canada [29%], United States [26%], France [9%], Japan [8%], and Thailand [5%]). Respondents were attending physicians (63%), nurses (13%), trainee physicians (9%), respiratory therapists (9%), and other (6%). Lower oxygen saturation, higher F io2 , noninvasive ventilation compared with high-flow, tachypnea, neck muscle use, abdominal paradox, drowsiness, and inability to obey were associated with increased odds of intubation; diagnosis, vasopressors, and duration of symptoms were not. Nurses were less likely than physicians to recommend intubation. Within a country, the odds of recommending intubation changed between clinicians by an average factor of 2.60; within a region, the same odds changed between countries by 1.56. Respondents from Canada (OR, 0.53; CrI, 0.40-0.70) and the United States (OR, 0.63; CrI, 0.48-0.84) were less likely to recommend intubation than respondents from most other countries. CONCLUSIONS: In this international, multiprofessional survey of 2294 clinicians, intubation for patients with AHRF was mostly decided based on oxygenation, breathing pattern, and consciousness, but there was important variation across individuals and countries.
Keywords: journalArticle; (CIHR) and the Interdepartmental Division of Critical Care Medicine at the; *Intubation, Intratracheal/statistics & numerical data; *Respiratory Insufficiency/therapy; Adult; Bayes Theorem; Care Medicine, University of Toronto. The remaining authors have disclosed that; Clinical Decision-Making; Fairley Professor of Critical Care at the Interdepartmental Division of Critical; Female; Foundation. Dr. Bellani receives lecturing fees from Draeger Medical and; He received support for article research from the CIHR. Dr; Humans; Hypoxia/therapy; Japan and the Japan Science and Technology Agency. Dr. Fowler is the H. Barrie; Male; Mellado-Artigas received funding from Merck (Sharp & Dohme). Dr. Yoshida received; Middle Aged; Surveys and Questionnaires; University of Toronto trainee award. He reports grant funding from the JP Bickell; and Zoll; consultancy fees from Flowmeter. Drs. Brochard and Mellado-Artigas received; funding from Medtronic and Fisher & Paykel. Dr. Brochard's institution received; funding from Stimit, Vitalaire, Cerebra Health, Sentec, and Philips. Dr. Goligher; funding from the Ministry of Education, Culture, Sports, Science and Technology,; received funding from Getinge, Heecap, Lungpacer, BioAge, Stimit, Vyaire, Drager,; they do not have any potential conflicts of interest