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Abstract
Background: Intubation and extubation of ventilated patients are not risk-free procedures in the intensive care unit
(ICU) and can be associated with morbidity and mortality. Intubation in the ICU is frequently required in emergency
situations for patients with an unstable cardiovascular or respiratory system. Under these circumstances, it is a high-
risk procedure with life-threatening complications (20–50%). Moreover, technical problems can also give rise to com‑
plications and several new techniques, such as videolaryngoscopy, have been developed recently. Another risk period
is extubation, which fails in approximately 10% of cases and is associated with a poor prognosis. A better understand‑
ing of the cause of failure is essential to improve success procedure.
Results and conclusion: In constructing these guidelines, the SFAR/SRLF experts have made use of new data on
intubation and extubation in the ICU from the last decade to update existing procedures, incorporate more recent
advances and propose algorithms.
© The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
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and indicate if changes were made.
Quintard et al. Ann. Intensive Care (2019) 9:13 Page 2 of 7
These can make up 10–20% of intubations in the ICU and As a first step, the organization committee defined the
are associated with an increase in morbidity [2]. Several questions under consideration according to the PICO
new techniques such as videolaryngoscopy have been format (Patients Intervention Comparison Outcome).
R 3.1—A hypnotic agent that facilitates rapid R 4.1—Non-invasive ventilation should probably be
sequence induction (RSI) should probably be used used for pre-oxygenation of hypoxaemic patients in
(Etomidate, Ketamine, Propofol), the choice depend- ICU. (Grade 2 +) Strong agreement.
ing on medical history and the clinical situation of R 4.2—It is possible to use high-flow nasal oxygen
the patient. (Grade 2 +) Strong agreement. (HFNO) for pre-oxygenation in ICU, especially for
R 3.2—In critically ill patients, to facilitate tracheal patients not severely hypoxaemic. (Expert opinion)
intubation during RSI (rapid sequence induction), Strong agreement.
succinylcholine use is probably recommended R 4.3—A protocol for intubation including a respira-
(Grade 2 +) Strong agreement. tory component should probably be used in ICU to
R 3.3—Rocuronium at a dose above 0.9 mg/kg [1.0– decrease respiratory complications. (Grade 2 +)
1.2 mg/kg] should be used when succinylcholine is Strong agreement.
contraindicated. (Grade 1 +) Sugammadex should R 4.4—A post-intubation recruitment manoeu-
probably be rapidly available when rocuronium is vre should probably be used in ICU in hypoxaemic
used (Grade 2 +) Strong agreement. patients, by integrating it into the respiratory com-
ponent. (Grade 2 +) Strong agreement.
Quintard et al. Ann. Intensive Care (2019) 9:13 Page 4 of 7
Looking for specific risk factors for extubaon failure* If present, delay extubaon (12-24h)
Bundles and intubation in PICU issues. SL, EJ, GO, SL, VL, OB validate the pediatric recommendations. HQ and
JP drafted the manuscript. All authors read and approved the final manuscript.
Consent for publication 6. Wang J, Ma Y, Fang Q. Extubation with or without spontaneous breathing
Not applicable. trial. Crit Care Nurse. 2013;33(6):50–5.
7. Boles J-M, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning
Ethics approval and consent to participate from mechanical ventilation. Eur Respir J. 2007;29(5):1033–56.
Not applicable. 8. Girard TD, Kress JP, Fuchs BD, Thomason JWW, Schweickert WD, Pun BT,
et al. Efficacy and safety of a paired sedation and ventilator weaning
Funding protocol for mechanically ventilated patients in intensive care (Awaken‑
This work was financially supported by the French Society of Anaesthesia and ing and Breathing Controlled trial): a randomised controlled trial. Lancet
Intensive Care Medicine. Lond Engl. 2008;371(9607):126–34.
9. Girard TD, Ely EW. Protocol-driven ventilator weaning: reviewing the
evidence. Clin Chest Med. 2008;29(2):241–52.
Publisher’s Note 10. Thille AW, Richard J-CM, Brochard L. The decision to extubate in the
Springer Nature remains neutral with regard to jurisdictional claims in pub‑ intensive care unit. Am J Respir Crit Care Med. 2013;187(12):1294–302.
lished maps and institutional affiliations. 11. Girault C, Bubenheim M, Abroug F, Diehl JL, Elatrous S, Beuret P, et al.
Noninvasive ventilation and weaning in patients with chronic hypercap‑
Received: 29 November 2018 Accepted: 3 January 2019 nic respiratory failure: a randomized multicenter trial. Am J Respir Crit
Care Med. 2011;184(6):672–9.
12. Thille AW, Boissier F, Ben-Ghezala H, Razazi K, Mekontso-Dessap A, Brun-
Buisson C, et al. Easily identified at-risk patients for extubation failure may
benefit from noninvasive ventilation: a prospective before-after study.
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