Withholding intubation clinically beneficial among comatose patients with suspected acute poisoning: JAMA

Coma or Comatose stage is characterized as a lengthy deep state of unconsciousness. People in a state of coma are alive but are unable to move or be aware of or respond to their surroundings. They lose their thinking abilities but retain non-cognitive function and normal sleep patterns. Acute poisoning caused by alcohol, drugs, or medication is a common non traumatic reason for a decreased level of consciousness and is often associated with a high rate of intubation.

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 according to a study published in JAMA Network.

Researchers conducted a multicenter, randomized trial 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. Patients were randomized to undergo conservative airway strategy of intubation withholding vs routine practice. 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.

The key findings of the study are

• Out of 225 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%]).

Researchers concluded that “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.”

Reference: Freund Y, Viglino D, Cachanado M, et al. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. Published online November 29, 2023. doi:10.1001/jama.2023.24391.