一项基于国际析因性病例描述的急性低氧性呼吸衰竭插管决策调查。

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

作者信息

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

机构信息

Department of Critical Care Medicine, Scarborough Health Network, Toronto, ON, Canada.

Scarborough Health Network Research Institute, Toronto, ON, Canada.

出版信息

Crit Care Med. 2025 Jan 1;53(1):e117-e131. doi: 10.1097/CCM.0000000000006494. Epub 2024 Nov 22.

DOI:10.1097/CCM.0000000000006494

PMID:39576153

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 F io2 , 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.

摘要

目的

气管插管是急性低氧性呼吸衰竭（AHRF）的常见操作，但指导决策的证据极少。我们开展了一项关于AHRF患者何时进行气管插管的调查，以评估临床变量对插管决策的影响并量化变异性。

设计

基于析因 vignette 的调查，询问“你会建议进行气管插管吗？”对于多达十个随机分配的 vignette，受访者从从“绝对不”到“绝对是”的 5 分制中选择一个序贯推荐。我们使用贝叶斯比例优势模型，并按个体、国家和地区进行聚类，以计算具有 95%可信区间（CrI）的平均优势比（OR）。

设置

基于网络的匿名调查。

受试者

参与气管插管决策的临床医生。

干预措施

无。

测量指标及主要结果

2023 年 9 月至 2024 年 1 月期间，74 个国家的 2294 名受访者录入了 17235 份 vignette 回复（最常见的国家：加拿大[29%]、美国[26%]、法国[9%]、日本[8%]和泰国[5%]）。受访者包括主治医师（63%）、护士（13%）、实习医生（9%）、呼吸治疗师（9%）和其他人员（6%）。较低的氧饱和度、较高的吸入氧分数值、与高流量相比的无创通气、呼吸急促、颈部肌肉使用、腹部矛盾运动、嗜睡和无法配合与气管插管几率增加相关；诊断、血管活性药物和症状持续时间则无关。护士比医生更不太可能建议进行气管插管。在一个国家内，临床医生之间建议进行气管插管的几率平均相差 2.60 倍；在一个地区内，不同国家之间相同几率相差 1.56 倍。来自加拿大（OR，0.53；CrI，0.40 - 0.70）和美国（OR，0.63；CrI，0.48 - 0.84）的受访者比大多数其他国家的受访者更不太可能建议进行气管插管。