• Audrey De Jong, Nicolas Molinari, Nicolas Terzi, Nicolas Mongardon, Jean-Michel Arnal, Christophe Guitton, Bernard Allaouchiche, Catherine Paugam-Burtz, Jean-Michel Constantin, Jean-Yves Lefrant, Marc Leone, Laurent Papazian, Karim Asehnoune, Nicolas Maziers, Elie Azoulay, Gael Pradel, Boris Jung, Samir Jaber, and AzuRéa Network for the Frida-Réa Study Group.
• Intensive Care and Anesthesiology Department, University of Montpellier Saint Eloi Hospital, Montpellier, France.
• Am. J. Respir. Crit. Care Med.. 2013 Apr 15;187(8):832-9.

RationaleDifficult intubation in the intensive care unit (ICU) is a challenging issue.ObjectivesTo develop and validate a simplified score for identifying patients with difficult intubation in the ICU and to report related complications.MethodsData collected in a prospective multicenter study from 1,000 consecutive intubations from 42 ICUs were used to develop a simplified score of difficult intubation, which was then validated externally in 400 consecutive intubation procedures from 18 other ICUs and internally by bootstrap on 1,000 iterations.Measurements And Main ResultsIn multivariate analysis, the main predictors of difficult intubation (incidence = 11.3%) were related to patient (Mallampati score III or IV, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening); pathology (severe hypoxia, coma); and operator (nonanesthesiologist). From the β parameter, a seven-item simplified score (MACOCHA score) was built, with an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.85-0.94). In the validation cohort (prevalence of difficult intubation = 8%), the AUC was 0.86 (95% CI, 0.76-0.96), with a sensitivity of 73%, a specificity of 89%, a negative predictive value of 98%, and a positive predictive value of 36%. After internal validation by bootstrap, the AUC was 0.89 (95% CI, 0.86-0.93). Severe life-threatening events (severe hypoxia, collapse, cardiac arrest, or death) occurred in 38% of the 1,000 cases. Patients with difficult intubation (n = 113) had significantly higher severe life-threatening complications than those who had a nondifficult intubation (51% vs. 36%; P < 0.0001).ConclusionsDifficult intubation in the ICU is strongly associated with severe life-threatening complications. A simple score including seven clinical items discriminates difficult and nondifficult intubation in the ICU. Clinical trial registered with www.clinicaltrials.gov (NCT 01532063).

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