Peri-intubation complications in critically ill obese patients: a secondary analysis of the international INTUBE cohort

Critical Care volume 29, Article number: 192 Published: 13 May 2025

Abstract

Background

Airway management in critically ill obese patients is potentially associated with a higher risk of adverse events due to a constellation of physiological and anatomical challenges. Data from international prospective studies on peri-intubation adverse events in obese critically ill patients are lacking.

Methods

INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was an international multicentre prospective cohort study enrolling critically ill adult patients undergoing in-hospital tracheal intubation in 197 sites from 29 countries worldwide from October 1, 2018, to July 31, 2019. This secondary analysis compares airway management practices and outcomes between obese (body mass index–BMI ≥ 30 kg/m²) and non-obese patients (BMI < 30 kg/m²).

Results

A total of 2946 patients met inclusion criteria for this secondary analysis, 639 (21.7%) obese and 2307 (78.3%) non-obese. Severe peri-intubation hypoxemia was more frequently reported in obese compared to non-obese patients (12.1% vs 8.6% respectively, p = 0.01). Variables independently associated with a higher risk of peri-intubation hypoxemia were baseline SpO₂/FiO₂ (OR 0.996, 95% CI 0.994–0.997), 30–45° head-up position (OR 1.53, 95% CI 1.04–2.26) and first-pass intubation failure (OR for first-pass success 0.21, 95% CI 0.15–0.29). Obesity (OR 0.71, 95% CI 0.56–0.91) and 20° head-up position (OR 0.67, 95% CI 0.47–0.95) were independently associated with higher likelihood of first-pass intubation failure. In contrast, intubation by staff physician/consultant (OR 1.70, 95% CI 1.30–2.21) or anesthesiologists (OR 1.98, 95% CI 1.55–2.53) were associated with higher first-pass success.

Conclusions

Compared to non-obese patients, obese critically ill exhibit a higher incidence of peri-intubation severe hypoxemia. In this population, worse baseline oxygenation and first-pass intubation failure significantly increase the risk of peri-intubation severe hypoxemia. As obesity is linked to a higher likelihood of first-pass intubation failure, likely driven by more challenging airway features, in this high-risk population first attempt should be performed by an expert operator to minimize peri-intubation complications.