Facilitating EndotracheaL Intubation by Laryngoscopy Technique and Apneic Oxygenation Within the Intensive Care Unit: The FELLOW Study

Not Applicable

Completed

Conditions: Respiratory Failure

Interventions: Device: Video Laryngoscopy
Device: Apneic Oxygenation
Device: Direct Laryngoscopy
Device: No Apneic Oxygenation

Registration Number: NCT02051816

Lead Sponsor: Vanderbilt University

Brief Summary: Respiratory failure requiring endotracheal intubation occurs in as many as 40% of critically ill patients. Procedural complications including failed attempts at intubation, esophageal intubation, arterial oxygen desaturation, aspiration, hypotension, cardiac arrest, and death are common in this setting. While there are many important components of successful airway management in critical illness, the maintenance of adequate arterial hemoglobin saturation from procedure initiation until endotracheal tube placement is paramount as desaturation is the most common factor associated with peri-intubation cardiac arrest and death. Interventions that either shorten the duration of time required for tube placement or prolong the period before desaturation may be effective in improving outcome. The high rate of complications and the lack of existing evidence regarding the efficacy of current airway management techniques in shortening the time to airway establishment or prolonging the time to desaturation mandates further investigation. The primary hypothesis is that video laryngoscopy will be superior to direct laryngoscopy in successful first attempt at endotracheal intubation (defined by confirmed placement of an endotracheal tube in the trachea during first laryngoscopy attempt) of medical ICU patients by Pulmonary/Critical Care Medicine fellows after controlling for the operator's past number of procedures with the equipment used. Also, the investigators hypothesize that the provision of apneic oxygenation during the endotracheal intubation procedure (defined as a nasal cannula with 15 liters per minute of oxygen flow placed prior to sedation or neuromuscular blockade and maintained until after completion of the procedure) will result in a higher arterial oxygen saturation nadir (defined as lowest noninvasive oxygenation saturation value observed between the administration of sedation and/or neuromuscular blockade and 2 minutes after successfully secured airway or death) compared to no apneic oxygenation.

Detailed Description: Not available

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 150

Inclusion Criteria

Adults
Medical ICU Patients
Require endotracheal intubation
Endotracheal intubation to be performed by Pulmonary/Critical Care Medicine Fellow
Sedation and/or neuromuscular blockade is planned for the procedure

Exclusion Criteria

Operators other than Pulmonary/Critical Care Medicine Fellows
The operator predetermines that the patient requires specific intubating equipment or oxygenation technique will be required for the safe performance of the procedure

Study & Design

Study Type: INTERVENTIONAL

Study Design: FACTORIAL

Arm && Interventions

Group	Intervention	Description
DL and no AO	Video Laryngoscopy	Direct Laryngoscopy and no apneic oxygenation
VL and AO	Apneic Oxygenation	Video laryngoscopy and apneic oxygenation
VL and no AO	Direct Laryngoscopy	Video Laryngoscopy and no apneic oxygenation
DL and no AO	Direct Laryngoscopy	Direct Laryngoscopy and no apneic oxygenation
VL and AO	No Apneic Oxygenation	Video laryngoscopy and apneic oxygenation
DL and AO	Apneic Oxygenation	Direct Laryngoscopy and apneic oxygenation
DL and AO	No Apneic Oxygenation	Direct Laryngoscopy and apneic oxygenation
VL and no AO	Video Laryngoscopy	Video Laryngoscopy and no apneic oxygenation

Primary Outcome Measures

Name	Time	Method
Successful First Attempt at Endotracheal Intubation (Defined by Confirmed Placement of an Endotracheal Tube in the Trachea During First Laryngoscopy Attempt) After Controlling for the Operator's Past Number of Procedures With the Equipment Used.	1 hour	The primary outcome for the video laryngoscopy compared with direct laryngoscopy arm of the study will be the successful first attempt at endotracheal intubation (defined by confirmed placement of an endotracheal tube in the trachea during first laryngoscopy attempt) after controlling for the operator's past number of procedures with the equipment used.
Arterial Oxygen Saturation Nadir (Defined as Lowest Noninvasive Oxygenation Saturation Value Observed Between the Administration of Sedation and/or Neuromuscular Blockade and 2 Minutes After Successfully Secured Airway or Death).	1 hour	The primary outcome for the apneic oxygenation arm of the study is arterial oxygen saturation nadir (defined as lowest noninvasive oxygenation saturation value observed between the administration of sedation and/or neuromuscular blockade and 2 minutes after successfully secured airway or death).

Secondary Outcome Measures

Name	Time	Method
Adjusted Lowest Arterial Oxygen Saturation During Procedure	1 hour	Arterial oxygen saturation nadir (defined as lowest noninvasive oxygenation saturation value observed between the administration of sedation and/or neuromuscular blockade and 2 minutes after successfully secured airway or death) adjusted for arterial oxygen saturation at the time of administering intubation drugs.
Ventilator-free Days	28 days	Number of days alive and free of mechanical ventilation after endotracheal intubation
Number of Esophageal Intubations Per Group	1 hour	Number of esophageal intubations Per Study Group
Procedure-related Mortality	1 hour	Death within 1 hour of beginning the procedure
ICU-mortality	28 days	Death from any cause in the ICU and at anytime after the procedure
Grade View of the Glottis	1 hour	Best Cormack-Lehane grade view of the glottis (grade 1-4) on first laryngoscopy attempt. Higher grades on the 1-4 scale indicate worse glottic views.