Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study.
BACKGROUND
Difficult intubation in the intensive care unit (ICU) is a challenging issue.


OBJECTIVE
To develop and validate a simplified score for identifying patients with difficult intubation in the ICU and to report related complications.


METHODS
Data collected in a prospective multicenter study from 1,000 consecutive intubations from 42 ICUs were used to develop a simplified score of difficult intubation, which was then validated externally in 400 consecutive intubation procedures from 18 other ICUs and internally by bootstrap on 1,000 iterations.


RESULTS
In multivariate analysis, the main predictors of difficult intubation (incidence = 11.3%) were related to patient (Mallampati score III or IV, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening); pathology (severe hypoxia, coma); and operator (nonanesthesiologist). From the β parameter, a seven-item simplified score (MACOCHA score) was built, with an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.85-0.94). In the validation cohort (prevalence of difficult intubation = 8%), the AUC was 0.86 (95% CI, 0.76-0.96), with a sensitivity of 73%, a specificity of 89%, a negative predictive value of 98%, and a positive predictive value of 36%. After internal validation by bootstrap, the AUC was 0.89 (95% CI, 0.86-0.93). Severe life-threatening events (severe hypoxia, collapse, cardiac arrest, or death) occurred in 38% of the 1,000 cases. Patients with difficult intubation (n = 113) had significantly higher severe life-threatening complications than those who had a nondifficult intubation (51% vs. 36%; P < 0.0001).


CONCLUSIONS
Difficult intubation in the ICU is strongly associated with severe life-threatening complications. A simple score including seven clinical items discriminates difficult and nondifficult intubation in the ICU. Clinical trial registered with www.clinicaltrials.gov (NCT 01532063).
Intensive Care and Anesthesiology Department, University of Montpellier Saint Eloi Hospital, Montpellier, France.
Audrey
A
De Jong
Nicolas
N
Molinari
Nicolas
N
Terzi
Nicolas
N
Mongardon
Jean-Michel
JM
Arnal
Christophe
C
Guitton
Bernard
B
Allaouchiche
Catherine
C
Paugam-Burtz
Jean-Michel
JM
Constantin
Jean-Yves
JY
Lefrant
Marc
M
Leone
Laurent
L
Papazian
Karim
K
Asehnoune
Nicolas
N
Maziers
Elie
E
Azoulay
Gael
G
Pradel
Boris
B
Jung
Samir
S
Jaber
D000368:Aged; D019540:Area Under Curve; D015992:Body Mass Index; D002574:Cervical Vertebrae / Q000473:pathology / Q000503:physiopathology; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007442:Intubation, Intratracheal / Q000009:adverse effects*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D051346:Mobility Limitation; D009055:Mouth / Q000503:physiopathology; D015999:Multivariate Analysis; D011446:Prospective Studies; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods*; D012720:Severity of Illness Index; D020181:Sleep Apnea, Obstructive / Q000150:complications