Experts’ guidelines of intubation and extubation of the ICU patient of French Society of Anaesthesia and Intensive Care Medicine (SFAR) and French-speaking Intensive Care Society (SRLF)

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 complications 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 understanding 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.


Introduction
Intubation and extubation of ventilated patients are not risk-free procedures on 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 system who may be hypoxic [1][2][3]. Under these circumstances it is a high-risk procedure with life-threatening complications (20-50%) such as hypotension and respiratory failure [2]. Technical problems can also give rise to complications. Generally three unsuccessful intubations [4] or two unsuccessful attempts at laryngoscopy are needed to justify the description difficult airway.
These can make up 10-20% of intubations in the ICU and are associated with an increase in morbidity [2]. Several new techniques such as videolaryngoscopy have been developed for difficult airway management, but contrary to operating room practice, integrating these into ICU algorithms is not well established.
Another period of risk is extubation, which fails in approximately 10% and is associated with a poor prognosis [5,6]. Extubation follows the successful weaning of patients from mechanical ventilation [7][8][9], but sometimes the re-establishment of spontaneous breathing is only possible with the tube in situ. An extubation failure is defined as the need for reintubation within 48 h of tube removal [7,10], and the most recent consensus on weaning defined success as an absence of mechanical assistance for 48 h after extubation. There is a need to incorporate into these definitions the development of noninvasive ventilation (NIV) after extubation. NIV can be used as a weaning aid during extubation or as a preventive or curative treatment in acute respiratory failure occurring after extubation [11,12]. As NIV can postpone the need for reintubation, a period of 7 days after extubation is required for a more accurate definition of failure [12]. To reduce the incidence of failure to extubate, the role of pathologies such as swelling and laryngeal edema in increasing risk must be appreciated. Screening for risk factors that might predispose to failure to extubate could improve the chances of success. In constructing these guidelines we have made use of new data on intubation and extubation in the ICU from the last decade to update existing procedures and incorporate more recent advances. Table 1 represents a total of 19 experts were separated into 7 working groups (the pediatric experts being involved in all questions): The management of intubation has been assessed according to four headings: complicated intubation in the ICU, the materials required, pharmacology and the use of a management protocol. Extubation has been assessed according to three headings: prerequisites for extubation, extubation failure and the use of a management protocol. A specific analysis was performed for intubation and extubation in children.

Materials and methods
As a first step, the organization committee defined the questions under consideration according to the PICO format (Patients Intervention Comparison Outcome). The system used to elaborate their recommendations is the GRADE ® method [13,14].
These guidelines with their arguments were published in the journal Anaesthesia Critical Care and Pain Medicine [15,16].
Intubation of the ICU patient ( Fig. 1) Complicated intubation in ICU R 1.1-All patients admitted to intensive care units must be considered at risk of complicated intubation. (Grade 1 +) Strong agreement. R 1.2-To reduce the incidence of complicated intubation, respiratory and haemodynamic complications must be anticipated and prevented, by careful preparing for intubation, and taking steps to maintain oxygenation and cardiovascular stability throughout the procedure. (Grade 1 +) Strong agreement.

Complicated intubation in pediatric intensive care unit (PICU)
R 1.1 (pediatric)-All patients admitted in pediatric intensive care units must be considered at risk of complicated intubation. (Grade 1 +) Strong agreement. R 1.2 (pediatric)-To reduce the incidence of complicated intubation in pediatric intensive care unit, respiratory and hemodynamic complications must be anticipated and prevented, thanks to a carefully preparation of intubation, including preservation of oxygenation and hemodynamic throughout the procedure. (Grade 1 +) Strong agreement.