Orotracheal intubation: medical knowledge and clinical practices in ICUs

Introduction

Orotracheal intubation (OT) is considered one of the main procedures in ICUs; however, it involves risks and complications. So, a deep theoretical knowledge of proper techniques is of utmost importance and, under ideal conditions, OT should follow a strict protocol. The present study aimed to evaluate medical knowledge about OT techniques and to identify the usual procedures.

Methods

A prospective study involving three different ICUs in a university hospital: anesthesiology ICU (ANEST), pneumology ICU (PNEUMO) and emergency room ICU (ER). All doctors that work in the ICUs and agreed to take part in the study completed, anonymously, a questionnaire containing demographic data and questions about OT. Statistical analysis was performed using EPI-INFO and results were considered significant if P < 0.05.

Results

Forty-six questionnaires were obtained from ANEST, 15 from PNEUMO and 19 from ER, corresponding to 86% of the doctors working in those units. Doctors from ANEST were significantly older than those from the other ICUs (33.6 ± 4.6, 29.6 ± 6.6 and 29.9 ± 5.3 for ANESTH, PNEUMO and ER, respectively, P = 0.006), with only 26.3% being residents (93.3% and 68.4% for PNEUMO and ER, P = 0.001), 43.5% were board-certified intensivists (6.7% and 10.5% for PNEUMO and ER, P = 0.003) and 77.3% had already attended a difficult airway training course (13.3% and 10.5% for PNEUMO and ER, P = 0.000). ANEST and ER have their own airway protocol and it is known by 95.5% and 26.3% of their doctors. Some clinical practices recommended in the airway protocol were generally adopted as the associated use of opioid and hypnotic (98.7%) and pre-oxygenation (91.3%). Midazolan was the preferred hypnotic; however, ANEST doctors use etomidate more frequently than PNEUMO and ER doctors. A suboccipital pad was always used by 45%, without differences among ICUs. Some practices are more frequently adopted by ANEST physicians than those from the others, such as routine use of muscle relaxant (65.2%, 13.3% and 26.3%, respectively, for ANEST, PNEUMO and ER, P = 0.000) and always considering ICU patients as nonfasting (34.8%, 13.3% and 10.5%, respectively, for ANEST, PNEUMO and ER, P = 0.002). Although the majority claimed to know the difference between rapid sequence and classic induction (93.3, 63.7 and 89.5 for ANEST, PNEUMO and ER, P = 0.02), they did not correctly point out those differences (mean note – 2.28 ± 0.92, 2.1 ± 0.87 and 1.9 ± 0.75, respectively, for ANEST, PNEUMO and ER, P = 0.379). Almost 100% of the doctors use the Sellick maneuver; however, only 15% in the correct moment and only 26.3 until OT is appropriately checked.

Conclusion

Medical knowledge about OT is not satisfactory, even among highly qualified doctors for this procedure. It is necessary to evaluate clinical practice to check compliance with the questionnaires answers and with clinical protocols. It would be possible, therefore, to identify iatrogenesis and complications that poor compliance may cause.