An International Factorial Vignette-Based Survey of Intubation Decisions in Acute Hypoxemic Respiratory Failure

Christopher J Yarnell; Arviy Paranthaman; Peter Reardon; Federico Angriman; Thiago Bassi; Giacomo Bellani; Laurent Brochard; Harm Jan De Grooth; Laura Dragoi; Syafruddin Gaus; Paul Glover; Ewan C Goligher; Kimberley Lewis; Baoli Li; Hashim Kareemi; Bharath Kumar Tirupakuzhi Vijayaraghavan; Sangeeta Mehta; Ricard Mellado-Artigas; Julie Moore; Idunn Morris; Georgiana Roman-Sarita; Tai Pham; Jariya Sereeyotin; George Tomlinson; Hannah Wozniak; Takeshi Yoshida; Rob Fowler; Canadian Critical Care Trials Group

doi:10.1097/CCM.0000000000006494

An International Factorial Vignette-Based Survey of Intubation Decisions in Acute Hypoxemic Respiratory Failure

Crit Care Med. 2024 Nov 22. doi: 10.1097/CCM.0000000000006494. Online ahead of print.

Authors

Christopher J Yarnell^{1

2

3}, Arviy Paranthaman¹, Peter Reardon¹, Federico Angriman^{3

4}, Thiago Bassi³, Giacomo Bellani^{5

6}, Laurent Brochard^{3

7}, Harm Jan De Grooth⁸, Laura Dragoi³, Syafruddin Gaus⁹, Paul Glover¹⁰, Ewan C Goligher^{3

11

12}, Kimberley Lewis^{13

14}, Baoli Li¹⁵, Hashim Kareemi¹⁶, Bharath Kumar Tirupakuzhi Vijayaraghavan¹⁷, Sangeeta Mehta^{3

18}, Ricard Mellado-Artigas¹⁹, Julie Moore^{15

20

21}, Idunn Morris^{12

22

23}, Georgiana Roman-Sarita²⁴, Tai Pham^{25

26}, Jariya Sereeyotin²⁷, George Tomlinson^{28

29}, Hannah Wozniak^{3

30}, Takeshi Yoshida³¹, Rob Fowler^{3

4

29

32

33}; Canadian Critical Care Trials Group

Affiliations

¹ Department of Critical Care Medicine, Scarborough Health Network, Toronto, ON, Canada.
² Scarborough Health Network Research Institute, Toronto, ON, Canada.
³ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
⁴ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
⁵ Centre for Medical Sciences (CISMed), University of Trento, Trento, Italy.
⁶ Anaesthesia and Intensive Care, Santa Chiara Hospital, APSS, Trento, Italy.
⁷ Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
⁸ Intensive Care Center, UMC Utrecht, Utrecht, The Netherlands.
⁹ Department of Anesthesiology, Intensive Care, and Pain Management; Faculty of Medicine, Hasanuddin University, Makassar, Indonesia.
¹⁰ Northern Ontario School of Medicine, Timmins and District Hospital, Timmins, ON, Canada.
¹¹ Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada.
¹² Department of Physiology, University of Toronto, Toronto, ON, Canada.
¹³ Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.
¹⁴ Department of Health Research, Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
¹⁵ Department of Nursing, Mount Sinai Hospital, Toronto, ON, Canada.
¹⁶ Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
¹⁷ Department of Critical Care Medicine, Apollo Hospitals, Chennai, India and Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom.
¹⁸ Department of Medicine, Sinai Health System, Toronto, ON, Canada.
¹⁹ Surgical ICU, Department of Anesthesiology, Hospital Clínic de Barcelona, Barcelona, Spain.
²⁰ Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
²¹ Trent-Fleming School of Nursing, Trent University, Peterborough, ON, Canada.
²² Nepean Clinical School, University of Sydney, Sydney, NSW, Australia.
²³ Department of Intensive Care Medicine, Nepean Hospital, Sydney, NSW, Australia.
²⁴ Department of Respiratory Therapy, University Health Network, Toronto, ON, Canada.
²⁵ Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche CARMAS, Le Kremlin-Bicêtre, France.
²⁶ Université Paris-Saclay, Université de Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm U1018, Équipe d'Épidémiologie Respiratoire Intégrative, Centre d' Épidémiologie et de Santé des Populations, Villejuif, France.
²⁷ Department of Anesthesiology, Division of Critical Care Medicine, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
²⁸ Department of Medicine, University Health Network, Toronto, ON, Canada.
²⁹ Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
³⁰ Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.
³¹ The Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan.
³² Department of Medicine, University of Toronto, Toronto, ON, Canada.
³³ Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.

PMID: 39576153
DOI: 10.1097/CCM.0000000000006494

Abstract

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 Fio2, 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.

Grants and funding

Trainee Award/University of Toronto Interdepartmental Division of Critical Care Medicine