title: Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events.
abstract: OBJECTIVE
  Prophylactic endotracheal intubation (PEI) is often advocated to mitigate the risk of cardiopulmonary adverse events in patients presenting with brisk upper GI bleeding (UGIB). However, the benefit of such a measure remains controversial. Our study aimed to compare the incidence of cardiopulmonary unplanned events between critically ill patients with brisk UGIB who underwent endotracheal intubation versus those who did not.
  
  
  METHODS
  Patients aged 18 years or older who presented at Cleveland Clinic between 2011 and 2014 with hematemesis and/or patients with melena with consequential hypovolemic shock were included. The primary outcome was a composite of several cardiopulmonary unplanned events (pneumonia, pulmonary edema, acute respiratory distress syndrome, persistent shock/hypotension after the procedure, arrhythmia, myocardial infarction, and cardiac arrest) occurring within 48 hours of the endoscopic procedure. Propensity score matching was used to match each patient 1:1 in variables that could influence the decision to intubate. These included Glasgow Blatchford Score, Charleston Comorbidity Index, and Acute Physiology and Chronic Health Evaluation scores.
  
  
  RESULTS
  Two hundred patients were included in the final analysis. The baseline characteristics, comorbidity scores, and prognostic scores were similar between the 2 groups. The overall cardiopulmonary unplanned event rates were significantly higher in the intubated group compared with the nonintubated group (20% vs 6%, P = .008), which remained significant (P = .012) after adjusting for the presence of esophageal varices.
  
  
  CONCLUSIONS
  PEI before an EGD for brisk UGIB in critically ill patients is associated with an increased risk of unplanned cardiopulmonary events. The benefits and risks of intubation should be carefully weighed when considering airway protection before an EGD in this group of patients.
authors.affiliation: Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Umar
authors.initials: U
authors.lastname: Hayat
authors.affiliation: Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Lee
authors.affiliation: Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Hamid
authors.initials: H
authors.lastname: Ullah
authors.affiliation: Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Shashank
authors.initials: S
authors.lastname: Sarvepalli
authors.affiliation: Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Rocio
authors.initials: R
authors.lastname: Lopez
authors.affiliation: Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: John J
authors.initials: JJ
authors.lastname: Vargo
mesh_terms: D000368:Aged; D001145:Arrhythmias, Cardiac / Q000453:epidemiology; D016022:Case-Control Studies; D015331:Cohort Studies; D016638:Critical Illness; D016145:Endoscopy, Digestive System / Q000379:methods*; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000601:surgery; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000601:surgery*; D006323:Heart Arrest / Q000453:epidemiology; D006331:Heart Diseases / Q000453:epidemiology*; D006396:Hematemesis; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D008171:Lung Diseases / Q000453:epidemiology*; D008297:Male; D008551:Melena; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology; D010438:Peptic Ulcer Hemorrhage / Q000601:surgery; D011014:Pneumonia / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology*; D011300:Preoperative Care / Q000379:methods*; D057216:Propensity Score; D011654:Pulmonary Edema / Q000453:epidemiology; D012128:Respiratory Distress Syndrome / Q000453:epidemiology; D012189:Retrospective Studies; D012771:Shock, Hemorrhagic / Q000453:epidemiology