High-risk acute pulmonary embolism (PE) is associated with significant mortality and may require emergency endotracheal intubation and mechanical ventilation. Intubation and ventilation are thought to exacerbate cardiorespiratory instability. Our purpose was to conduct a systematic literature review to identify studies investigating peri-intubation events in acute PE.
Methods
A systematic search of Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library was performed. Results were screened by two independent observers. Studies reporting on intubation and positive pressure ventilation in acute PE patients were included. The primary outcome was adverse events during the peri-intubation period. Data was synthesized and an assessment of risk of bias was conducted. The review was registered on PROSPERO (CRD42023444483).
Results
4100 unique articles were screened. Three retrospective studies comprising 104 patients with acute PE met criteria and were included. Peri-intubation, hemodynamic collapse was observed in 19%-28% of cases. Patients with hemodynamic collapse exhibited higher rates of echocardiographic RV dysfunction.
Conclusions
Peri-intubation adverse events are common in patients with acute PE. Current evidence is limited and highlights the need for further research to optimize management of respiratory failure in acute PE and patient selection for intubation to improve patient outcomes.
KonstantinidesSVMeyerGBecattiniC, et al.2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European respiratory society (ERS). Eur Heart J. 2020;41(4):543-603. doi:10.1093/eurheartj/ehz405
2.
LyhneMDKlineJANielsen-KudskJEAndersenA. Pulmonary vasodilation in acute pulmonary embolism – a systematic review. Pulm Circ. 2020;10(1):1-16. doi:10.1177/2045894019899775
3.
OshoAADudzinskiDM. Interventional therapies for acute pulmonary embolism. Surg Clin North Am. 2022;102(3):429-447. doi:10.1016/j.suc.2022.02.004
4.
KabrhelCOkechukwuIHariharanP, et al.Factors associated with clinical deterioration shortly after PE. Thorax. 2014;69(9):835-842. doi:10.1136/thoraxjnl-2013-204762
5.
MessikaJGoutorbePHajageDRicardJD. Severe pulmonary embolism managed with high-flow nasal cannula oxygen therapy. Eur J Emerg Med. 2017;24(3):230-232. doi:10.1097/mej.0000000000000420
6.
KhemasuwanDYingchoncharoenTTunsuponP, et al.Right ventricular echocardiographic parameters are associated with mortality after acute pulmonary embolism. J Am Soc Echocardiogr. 2015;28(3):355-362. doi:10.1016/j.echo.2014.11.012
7.
WintertonDBaileyMPilcherDLandoniGBellomoR. Characteristics, incidence and outcome of patients admitted to intensive care because of pulmonary embolism. Respirology. 2017;22(2):329-337. doi:10.1111/resp.12881
8.
JanataKHolzerMDomanovitsH, et al.Mortality of patients with pulmonary embolism. Wien Klin Wochenschr. 2002;114(17-18):766-772.
AlviarCLMillerPEMcAreaveyD, et al.Positive pressure ventilation in the cardiac intensive care unit. J Am Coll Cardiol. 2018;72(13):1532-1553. doi:10.1016/j.jacc.2018.06.074
11.
Al-SaadiMAHeidariBDonahueKRShipmanEMKinariwalaKNMasudFN. Pre-Existing right ventricular dysfunction as an independent risk factor for post intubation cardiac arrest and hemodynamic instability in critically ill patients: A retrospective observational study. J Intensive Care Med. 2022;38(2):169-178. doi:10.1177/08850666221111776
12.
FrancisSKabrhelC. Current controversies in caring for the critically ill pulmonary embolism patient. Emerg Med Clin North Am. 2020;38(4):931-944. doi:10.1016/j.emc.2020.06.012
13.
JaffMRMcMurtryMSArcherSL, et al.Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension. Circulation. 2011;123(16):1788-1830. doi:10.1161/cir.0b013e318214914f
14.
Rivera-LebronBMcDanielMAhrarK, et al.Diagnosis, treatment and follow up of acute pulmonary embolism: Consensus practice from the PERT consortium. Clin Appl Thromb Hemost. 2019;25:1076029619853037. doi:10.1177/1076029619853037
15.
AraújoBRiveraAMartinsS, et al.Video versus direct laryngoscopy in critically ill patients: An updated systematic review and meta-analysis of randomized controlled trials. Crit Care. 2024;28(1):1. doi:10.1186/s13054-023-04727-9
16.
BandyopadhyayAKumarPJafraAThakurHYaddanapudiLNJainK. Peri-Intubation hypoxia after delayed versus rapid sequence intubation in critically injured patients on arrival to trauma triage: A randomized controlled trial. Anesth Analg. 2023;136(5):913-919. doi:10.1213/ane.0000000000006171
17.
RussellDWCaseyJDGibbsKW, et al.Effect of fluid bolus administration on cardiovascular collapse among critically ill patients undergoing tracheal intubation. JAMA. 2022;328(3):270-279. doi:10.1001/jama.2022.9792
18.
LevinNMFixMLAprilMDAranaAABrownCAInvestigatorsN. The association of rocuronium dosing and first-attempt intubation success in adult emergency department patients. Can J Emerg Med. 2021;23(4):518-527. doi:10.1007/s43678-021-00119-6
19.
PageMJMcKenzieJEBossuytPM, et al.The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Br Med J. 2021;372:n71. doi:10.1136/bmj.n71
20.
McHughML. Interrater reliability: The kappa statistic. Biochem Med. 2012;22(3):276-282. doi:10.11613/bm.2012.031
21.
MunnZBarkerTHMoolaS, et al.Methodological quality of case series studies: An introduction to the JBI critical appraisal tool. JBI Evid Synth. 2019;18(10):2127-2133. doi:10.11124/jbisrir-d-19-00099
22.
WiegandUKHKurowskiVGiannitsisEKatusHADjonlagicH. Effectiveness of end-tidal carbon dioxide tension for monitoring of thrombolytic therapy in acute pulmonary embolism. Crit Care Med. 2000;28(11):3588-3592. doi:10.1097/00003246-200011000-00003
23.
RosenbergerPShernanSKShekarPS, et al.Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy. Anesth Analg. 2006;102(5):1311-1315. doi:10.1213/01.ane.0000208970.14762.7f
MunnZPetersMDJSternCTufanaruCMcArthurAAromatarisE. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):143. doi:10.1186/s12874-018-0611-x
26.
SantolicandroAPredilettoRFornaiE, et al.Mechanisms of hypoxemia and hypocapnia in pulmonary embolism. Am J Respir Crit Care Med. 1995;152(1):336-347. doi:10.1164/ajrccm.152.1.7599843
27.
BernardSNamasivayamMDudzinskiDM. Reflections on echocardiography in pulmonary embolism—literally and figuratively. J Am Soc Echocardiogr. 2019;32(7):807-810. doi:10.1016/j.echo.2019.05.007
28.
KonstamMAKiernanMSBernsteinD, et al.Evaluation and management of right-sided heart failure: A scientific statement from the American Heart Association. Circulation. 2018;137(20):e578-e622. doi:10.1161/cir.0000000000000560
29.
LiYLighthallG. Factors associated with 30- and 90-day mortality in intubations among critically ill patients. Acta Anaesthesiol Scand. 2024;68(2):206-213. doi:10.1111/aas.14334
30.
HongAWToppenWLeeJWilhalmeHSaggarRBarjaktarevicIZ. Outcomes and prognostic factors of pulmonary hypertension patients undergoing emergent endotracheal intubation. J Intensive Care Med. 2022;38(3):280-289. doi:10.1177/08850666221118839
31.
RushBBiagioniBJBergerLMcDermidR. Mechanical ventilation outcomes in patients with pulmonary hypertension in the United States: A national retrospective cohort analysis. J Intensive Care Med. 2016;32(10):588-592. doi:10.1177/0885066616653926
32.
VahdatpourCARyanJJZimmermanJM, et al.Advanced airway management and respiratory care in decompensated pulmonary hypertension. Heart Fail Rev. 2022;27(5):1807-1817. doi:10.1007/s10741-021-10168-9
33.
DriverBEPrekkerMEKleinLR, et al.Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: A randomized clinical trial. JAMA. 2018;319(21):2179. doi:10.1001/jama.2018.6496
34.
Garnacho-MonteroJGordillo-EscobarETrenadoJ, et al.A nationwide, prospective study of tracheal intubation in critically ill adults in Spain: Management, associated complications, and outcomes. Crit Care Med. 2024;52(5):786-797. doi:10.1097/ccm.0000000000006198
35.
FathySHasaninAMostafaM, et al.The benefit of adding lidocaine to ketamine during rapid sequence endotracheal intubation in patients with septic shock: A randomised controlled trial. Anaesth Crit Care Pain Med. 2021;40(1):100731. doi:10.1016/j.accpm.2020.06.017
36.
StollingsJLDiedrichDAOyenLJBrownDR. Rapid-Sequence intubation. Ann Pharmacother. 2014;48(1):62-76. doi:10.1177/1060028013510488
37.
CherfanPAliANAZaghloulMS, et al.Propofol administration during catheter-directed interventions for intermediate-risk pulmonary embolism is associated with major adverse events. J Vasc Surg Venous Lymphat Disord. 2021;9(3):621-626. doi:10.1016/j.jvsv.2020.08.026
38.
HoustonBABrittainELTedfordRJ. Right ventricular failure. New Engl J Med. 2023;388(12):1111-1125. doi:10.1056/nejmra2207410
39.
JohannesJBerlinDAPatelP, et al.A technique of awake bronchoscopic endotracheal intubation for respiratory failure in patients with right heart failure and pulmonary hypertension. Crit Care Med. 2017;45(9):e980-e984. doi:10.1097/ccm.0000000000002586
40.
StenglMLedvinovaLChvojkaJ, et al.Effects of clinically relevant acute hypercapnic and metabolic acidosis on the cardiovascular system: An experimental porcine study. Crit Care. 2013;17(6):R303. doi:10.1186/cc13173
41.
FriedmanOHorowitzJMRamzyD. Advanced cardiopulmonary support for pulmonary embolism. Tech Vasc Interv Radiol. 2017;20(3):179-184. doi:10.1053/j.tvir.2017.07.007
42.
ArrigoMPriceSHarjolaVP, et al.Diagnosis and treatment of right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale): A clinical consensus statement of the association for acute CardioVascular care of the European Society of Cardiology. Eur Heart J Acute Cardiovasc Care. 2023;13(3):304-312. doi:10.1093/ehjacc/zuad157
43.
MillingtonSJAissaouiNBowcockE, et al.High and intermediate risk pulmonary embolism in the ICU. Intensive Care Med. 2024;50(2):195-208. doi:10.1007/s00134-023-07275-6
44.
Pérez-NietoORGómez-OropezaIQuintero-LeyraA, et al.Hemodynamic and respiratory support in pulmonary embolism: A narrative review. Front Med. 2023;10:1123793. doi:10.3389/fmed.2023.1123793
45.
ErganBErgünRÇalışkanT, et al.Mortality related risk factors in high-risk pulmonary embolism in the ICU. Can Respir J. 2016;2016(43):2432808. doi:10.1155/2016/2432808
46.
KobayashiTPuglieseSSethiSS, et al.Contemporary management and outcomes of patients with high-risk pulmonary embolism. J Am Coll Cardiol. 2024;83(1):35-43. doi:10.1016/j.jacc.2023.10.026
47.
SohSKimJMParkJHKohSONaS. Delayed anticoagulation is associated with poor outcomes in high-risk acute pulmonary embolism. J Crit Care. 2016;32:21-25. doi:10.1016/j.jcrc.2015.11.024
48.
DomaradzkiLGhahramaniMRogersRRuziehMWilsonRde LouwAV. Spo2 /FIO2 on presentation as a predictor for early hemodynamic deterioration in intermediate risk acute pulmonary embolism. Respir Care. 2019;64(10):1279-1285. doi:10.4187/respcare.06797
49.
ArgyriouAVohraHChanJ, et al.Incidence and outcomes of surgical pulmonary embolectomy in the UK. Br J Surg. 2024;111(1):znae003. doi:10.1093/bjs/znae003
50.
UtsunomiyaTKrauszMMValeriCRLevineLSheproDHechtmanHB. Treatment of pulmonary embolism with positive end-expiratory pressure and prostaglandin E1. Surg Gynecol Obstet. 1981;153(2):161-168.
WoodGMadsenTLKimWYLyhneMD. Increasing levels of positive End-expiratory pressure cause stepwise biventricular stroke work reduction in a porcine model. Anesthesiology. 2024;140(2):240-250. doi:10.1097/aln.0000000000004821
53.
YusuffHChawlaSSatoR, et al.Mechanisms of acute right ventricular injury in cardiothoracic surgical and critical care settings: Part 2. J Cardiothorac Vasc Anesthesia. 2023;37(11):2318-2326. doi:10.1053/j.jvca.2023.07.018
54.
PaternotARepesséXVieillard-BaronA. Rationale and description of right ventricle-protective ventilation in ARDS. Respir Care. 2016;61(10):1391-1396. doi:10.4187/respcare.04943
55.
DahlemPBosAPHaitsmaJJSchultzMJMeijersJCMLachmannB. Alveolar fibrinolytic capacity suppressed by injurious mechanical ventilation. Intensive Care Med. 2005;31(5):724-732. doi:10.1007/s00134-005-2588-2
56.
SchultzMJLeviM. Pulmonary coagulopathy: A potential therapeutic target in different forms of lung injury. Thorax. 2007;62(7):563. doi:10.1136/thx.2006.067256
57.
KhoslaAZhaoYMojibianHPollakJSinghI. High-Risk pulmonary embolism: Management for the intensivist. J Intensive Care Med. 2023;38(12):1087-1098. doi:10.1177/08850666231188290
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