Implementation of a Revised Montpellier Bundle on the Outcome of Intubation in Critically Ill Patients: A Quality Improvement Project
Keywords :
Endotracheal intubation, Intensive care unit, Intubation bundle, Intubation complications, Quality improvement
Citation Information :
Implementation of a Revised Montpellier Bundle on the Outcome of Intubation in Critically Ill Patients: A Quality Improvement Project. Indian J Crit Care Med 2022; 26 (10):1106-1114.
Introduction: The feasibility of implementing a revised Montpellier intubation bundle incorporating recent evidences was tested in a quality-improvement project. It was hypothesized that this “Care Bundle” implementation would reduce intubation-related complications.
Materials and methods: The project was conducted in an 18-bedded multidisciplinary intensive care unit (ICU). Baseline data for intubations were collected over 3-month “Control Period”. During the 2-month “Interphase”, a revised intubation bundle was developed, and staff members involved in the intubation process were extensively trained on different aspects of intubation with emphasis on bundle components. Various components of the bundle were pre-intubation fluid loading, pre-oxygenation with NIV plus PS, positive-pressure ventilation post-induction, succinylcholine as a first-line induction agent, routine use of stylet, and lung recruitment within 2 minutes of intubation. Intubation data were collected again in the 3-month “Intervention Period”.
Results: Data were collected for 61 and 64 intubations, respectively, during control and intervention periods. There was significant improvement in compliance to five of six-bundle components; improvement in pre-intubation fluid loading during the intervention period did not reach statistical significance. Overall, at least 3 components of the bundle were complied within over 92% of intubations in the intervention period. However, whole-bundle compliance was limited to 14.3%. Incidences of major complications were reduced significantly in the intervention period (23.8% vs 45.9%, p = 0.01). There was significant reduction in profound hypotension (21.77% vs 29.51%, p = 0.04) and a nonsignificant 11.89% reduction in profound hypoxemia. There were no differences in minor complications.
Conclusion: Implementation of an evidence-based revised Montpellier intubation bundle is feasible and it reduces major complications related to endotracheal intubation.
Simpson GD, Ross MJ, McKeown DW, Ray DC. Tracheal intubation in the critically ill: a multi-centre national study of practice and complications. Br J Anaesth 2012;108:792–799.
Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, et al. Intubation practices and adverse peri-intubation events in critically ill patients from 29 Countries. JAMA 2021;325(12):1164–1172. DOI: 10.1001/jama.2021.1727.
Jaber S, Amraoui J, Lefrant JY, Arich C, Cohendy R, Landreau L, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: A prospective, multiple-center study. Crit Care Med 2006;34(9):2355–2361. DOI: 10.1097/01.CCM.0000233879.58720.87.
Griesdale DE, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008;34(10):1835–1842. DOI: 10.1007/s00134-008-1205-6.
De Jong A, Rolle A, Molinari N, Paugam-Burtz C, Constantin JM, Lefrant JY, et al. Cardiac arrest and mortality related to intubation procedure in critically ill adult patients: A multicenter cohort study. Crit Care Med 2018;46(4):532–539. DOI: 10.1097/CCM.000000000 0002925.
Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: A prospective, multiple-center study. Intensive Care Med 2010;36(2):248–255. DOI: 10.1007/s00134-009-1717-8.
Corl KA, Dado C, Agarwal A, Azab N, Amass T, Marks SJ, et al. A modified Montpellier protocol for intubating intensive care unit patients is associated with an increase in first-pass intubation success and fewer complications. J Crit Care 2018;44:191–195. DOI: 10.1016/j.jcrc.2017.11.014.
Constantin JM, Futier E, Cherprenet al, Chanques G, Guerin R, Cayot-Constantin S, et al. A recruitment maneuver increases oxygenation after intubation of hypoxemic intensive care unit patients: A randomized controlled study. Crit Care 2010;14(2):R76. DOI: 10.1186/cc8989.
Casey JD, Janz DR, Russell DW, Vonderhaar DJ, Joffe AM, Dischert KM, et al. Bag-mask ventilation during tracheal intubation of critically ill adults. N Engl J Med 2019;380(9):811–821. DOI: 10.1056/NEJMoa1812405.
Jaber S, Rollé A, Godet T, Terzi N, Riu B, Asfar P, et al. Effect of the use of an endotracheal tube and stylet versus an endotracheal tube alone on first-attempt intubation success: A multicentre, randomised clinical trial in 999 patients. Intensive Care Med 2021;47(6):653–664. DOI: 10.1007/s00134-021-06417-y.
Baillard C, Fosse JP, Sebbane M, Chanques G, Vincent F, Courouble P, et al. Non-invasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med 2006;174(2):171–177. DOI: 10.1164/rccm.200509-1507OC.
Marsch SC, Steiner L, Bucher E, Pargger H, Schumann M, Aebi T, et al. Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: A prospective, randomized controlled trial. Crit Care 2011;15(4):R199. DOI: 10.1186/cc10367.
Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2015;2015(10):CD002788. DOI: 10.1002/14651858.CD002788.pub3.
Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984;39(11):1105–1111. PMID: 6507827.
Adnet F, Borron SW, Racine SX, Clemessy JL, Fournier JL, Plaisance P, et al. The intubation difficulty scale (IDS): Proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology 1997;87(6):1290–1297. DOI: 10.1097/00000542-199712000-00005.
Perbet S, De Jong A, Delmas J, Futier E, Pereira B, Jaber S, et al. Incidence of and risk factors for severe cardiovascular collapse after endotracheal intubation in the ICU: A multicenter observational study. Crit Care 2015;19(1):257. DOI: 10.1186/s13054-015-0975-9.
Janz DR, Casey JD, Semler MW, Russell DW, Dargin J, Vonderhaar DJ, et al. Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): A randomised controlled trial. Lancet Respir Med 2019;7(12):1039–1047. DOI: 10.1016/S2213-2600(19)30246-2.
Baillard C, Prat G, Jung B, Futier E, Lefrant JY, Vincent F, et al. Effect of preoxygenation using non-invasive ventilation before intubation on subsequent organ failures in hypoxemic patients: A randomised clinical trial. Br J Anaesth 2018;120(2):361–367. DOI: 10.1016/j.bja.2017.11.067.
Jaber S, Monnin M, Girard M, Conseil M, Cisse M, Carr J, et al. Apnoeic oxygenation via high-flow nasal cannula oxygen combined with non-invasive ventilation preoxygenation for intubation in hypoxemic patients in the intensive care unit: The single-centre, blinded, randomised controlled OPTINIV trial. Intensive Care Med 2016;42(12):1877–1887. DOI: 10.1007/s00134-016-4588-9.
De Jong A, Rolle A, Pensier J, Capdevila M, Jaber S. First-attempt success is associated with fewer complications related to intubation in the intensive care unit. Intensive Care Med 2020;46(6):1278–1280. DOI: 10.1007/s00134-020-06041-2.