Original Investigation  Caring for the Critically Ill Patient

November 29, 2023

Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial

Yonathan Freund, Damien Viglino, Marine Cachanado, et al

JAMA. Published online November 29, 2023. doi:10.1001/jama.2023.24391

Key Points

Question  In patients with suspected poisoning and Glasgow Coma Scale score less than 9, is a conservative airway strategy of withholding intubation associated with a reduction of death, intensive care unit length of stay, and hospital length of stay compared with routine practice?

Findings  In this multicenter, randomized clinical trial that included 225 patients, a strategy of withholding intubation was associated with a significant clinical benefit for the primary end point in the intervention group, with a win ratio of 1.85 and a reduced adverse event risk rate (6% vs 14.7%; absolute risk difference, 8.6%) compared with the control group.

Meaning  Among comatose patients with suspected acute poisoning, a conservative strategy of withholding intubation was associated with a greater clinical benefit for the composite end point of in-hospital death, length of intensive care unit stay, and length of hospital stay.

Abstract

Importance  Tracheal intubation is recommended for coma patients and those with severe brain injury, but its use in patients with decreased levels of consciousness from acute poisoning is uncertain.

Objective  To determine the effect of intubation withholding vs routine practice on clinical outcomes of comatose patients with acute poisoning and a Glasgow Coma Scale score less than 9.

Design, Setting, and Participants  This was a multicenter, randomized trial conducted in 20 emergency departments and 1 intensive care unit (ICU) that included comatose patients with suspected acute poisoning and a Glasgow Coma Scale score less than 9 in France between May 16, 2021, and April 12, 2023, and followed up until May 12, 2023.

Intervention  Patients were randomized to undergo conservative airway strategy of intubation withholding vs routine practice.

Main Outcomes and Measures  The primary outcome was a hierarchical composite end point of in-hospital death, length of ICU stay, and length of hospital stay. Key secondary outcomes included adverse events resulting from intubation as well as pneumonia within 48 hours.

Results  Among the 225 included patients (mean age, 33 years; 38% female), 116 (16%) were in the intervention group and 109 (58%) in the control group. No patients died during the in-hospital stay. There was a significant clinical benefit for the primary end point in the intervention group, with a win ratio of 1.85 (95% CI, 1.33 to 2.58). In the intervention group, there was a lower proportion with any adverse event (6% vs 14.7%; absolute risk difference, 8.6% [95% CI, −16.6% to −0.7%]) compared with the control group, and pneumonia occurred in 8 (6.9%) and 16 (14.7%) patients, respectively (absolute risk difference, −7.8% [95% CI, −15.9% to 0.3%]).

Conclusions and Relevance  Among comatose patients with suspected acute poisoning, a conservative strategy of withholding intubation was associated with a greater clinical benefit for the composite end point of in-hospital death, length of ICU stay, and length of hospital stay.

Trial Registration  ClinicalTrials.gov Identifier: NCT04653597