© 2008 American Thoracic Society
Noninvasive Ventilation and Intubation of Hypoxic Patients: ICU versus Operating RoomFrom the Authors:We thank Dr. Sorbello and colleagues for their comments on our article (1). They point out the impressive difference between our results obtained in the intensive care unit (ICU) and epidemiological data regarding both the complexity of endotracheal intubation (ETI) and the incidence of severe desaturation. They propose to define airway management guidelines specifically designed for the ICU to raise safety standards. To date there is no study comparing the ETI difficulty between ICU and operating room settings. However, there is evidence for increased complexity of ETI outside the operating room. Adnet and colleagues developed an intubation difficulty scale (IDS), based on several parameters known to be associated with difficult ETI (2). Such an approach allows uniform comparison of different populations under varying circumstances. They also observed significantly greater IDS values in the prehospital setting as compared with the operating room (2). An IDS value more than 5 (reflecting a moderate to major ETI difficulty) was found in 7.4% of 1,442 prehospital patients (3), whereas in our study an IDS value greater than 5 was found in 8% of patients (1). For emergency airway management in critically ill adults, Schwartz and colleagues found that more than one attempt was required in more than 25% of almost 300 ETI (4). Moreover, in a recent French multicenter ICU survey, 25% of 253 intubations required at least two attempts (5). The ETI difficulty correlates with the time to intubation (2) and enhances the rate of hypoxemia (6). As a result severe desaturation during ETI is frequently encountered in the ICU (1, 6). We agree with Dr. Sorbello and colleagues that airway management in the ICU should take into account the complexity of this setting and that "behaviors, algorithms, and procedures in specific guidelines" should be defined. Their balanced comments on the use of "laryngeal mask airway (LMA) as a potential intermediate approach for preoxygenation" explain the differences of the ICU environment compared with other clinical settings, such as the operating room. In the ICU, LMA insertion and tolerance require deep sedation and should be preceded by a preoxygenation method in the same way as ETI. Consequently, LMA should be viewed as a rescue approach to solve a cannot-ventilate/cannot-intubate situation rather than a preoxygenation method.
DAR Avicenne Hospital
DAR B University Hospital of Montpellier FOOTNOTES Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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