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EFFECT OF NONINVASIVE AIRWAY MANAGEMENT OF COMATOSE PATIENTS WITH ACUTE
POISONING: A RANDOMIZED CLINICAL TRIAL.

Yonathan Freund, Damien Viglino, Marine Cachanado, Clémentine Cassard, Emmanuel
Montassier, Bénedicte Douay, Jérémy Guenezan, Pierrick Le Borgne, Youri
Yordanov, Armelle Severin, Mélanie Roussel, Matthieu Daniel, Adrien Marteau,
Nicolas Peschanski, Dorian Teissandier, Richard Macrez, Julia Morere, Tahar
Chouihed, Damien Roux, Frédéric Adnet, Ben Bloom, Anthony Chauvin, Tabassome
Simon
JAMA 2023 November 30
IMPORTANCE: Tracheal intubation is recommended for coma patients and those with
severe brain injury, but its use in patients with decreased levels of
consciousness from acute poisoning is uncertain.

OBJECTIVE: To determine the effect of intubation withholding vs routine practice
on clinical outcomes of comatose patients with acute poisoning and a Glasgow
Coma Scale score less than 9.

DESIGN, SETTING, AND PARTICIPANTS: This was a multicenter, randomized trial
conducted 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 between May 16, 2021, and April 12, 2023, and
followed up until May 12, 2023.

INTERVENTION: Patients were randomized to undergo conservative airway strategy
of intubation withholding vs routine practice.

MAIN OUTCOMES AND MEASURES: 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.

RESULTS: Among the 225 included 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%]).

CONCLUSIONS AND RELEVANCE: 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.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04653597.



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