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. 2025 Apr 17;29(1):155.
doi: 10.1186/s13054-025-05392-w.

Peri-intubation adverse events and clinical outcomes in emergency department patients: the BARCO study

Ian Ward A Maia  1   2 , Bruno A M Pinheiro Besen  3 , Lucas Oliveira J E Silva  4   5 , Rafael von Hellmann  6 , Ludhmila Abrahao Hajjar  7 , Benjamin J Sandefur  4 , Daniel Fontana Pedrollo  5 , Caio Goncalves Nogueira  8 , Natalia Mansur P Figueiredo  8 , Carlos Henrique Miranda  9 , Danilo Martins  10 , Thiago Dias Baumgratz  10 , Bruno Bergesch  11 , Diogo Costa  11 , Osmar Colleoni  12 , Juliana Zanettini  13 , Ana Paula Freitas  13 , Nicole Pinheiro Moreira  14 , Patricia Lopes Gaspar  14   15 , Renato Tambelli  16 , Maria Cristina Costa  17 , Samara Silveira  17 , Wilsterman Correia  18 , Rafael Garcia de Maria  19 , Ubirajara A Vinholes Filho  20 , Andre P Weber  21 , Vinicius da Silva Castro  22 , Carlos Fernando D Dornelles  23 , Barbara S Tabach  23 , Hélio P Guimarães  7 , Gabriela Stanzani  7 , Thiago F Gava  7 , Aidan Mullan  4 , Heraldo P Souza  7 , Otavio T Ranzani  24   25 , Fernanda Bellolio  4 , Julio C G Alencar  26 ; BARCO group
Collaborators, Affiliations

Peri-intubation adverse events and clinical outcomes in emergency department patients: the BARCO study

Ian Ward A Maia et al. Crit Care. .

Erratum in

  • Correction: Peri-intubation adverse events and clinical outcomes in emergency department patients: the BARCO study.
    Maia IWA, Besen BAMP, Silva LOJE, von Hellmann R, Hajjar LA, Sandefur BJ, Pedrollo DF, Nogueira CG, Figueiredo NMP, Miranda CH, Martins D, Baumgratz TD, Bergesch B, Costa D, Colleoni O, Zanettini J, Freitas AP, Moreira NP, Gaspar PL, Tambelli R, Costa MC, Silveira S, Correia W, de Maria RG, Filho UAV, Weber AP, da Silva Castro V, Dornelles CFD, Tabach BS, Guimarães HP, Stanzani G, Gava TF, Mullan A, Souza HP, Ranzani OT, Bellolio F, Alencar JCG; BARCO group. Maia IWA, et al. Crit Care. 2025 Jun 10;29(1):235. doi: 10.1186/s13054-025-05450-3. Crit Care. 2025. PMID: 40495224 Free PMC article. No abstract available.

Abstract

Background: Emergency tracheal intubation in critically ill patients carries a high risk of complications, and practices vary substantially across different settings. Identifying risk factors and understanding how peri-intubation adverse events affect patient outcomes may guide standardization of care and improve survival.

Methods: This prospective cohort study involved 18 emergency departments in Brazil (March 2022-April 2024). We included adults (≥ 18 years) undergoing emergency intubation and excluded patients intubated electively or for cardiac arrest. We defined major peri-intubation adverse events as severe hypoxemia, new hemodynamic instability, or cardiac arrest occurring within 30 min of initiating intubation. The primary outcome was 28-day mortality. Multivariable regression analyses assessed associations between adverse events and mortality, controlling for potential confounders.

Results: Among 2846 patients, major adverse events occurred in 919 (32.3%) intubations, most frequently new hemodynamic instability (20.0%), followed by severe hypoxemia (12.5%) and cardiac arrest (3.5%). The overall 28-day mortality was 45.1%. Patients experiencing any major adverse event had a significantly higher 28-day mortality (57.6 vs 39.2%; aHR 1.43, 95% CI 1.26-1.62; p < 0.001). Sensitivity analyses confirmed these findings. Successful first-attempt intubation was associated with a reduced likelihood of major adverse events (aOR 0.52; 95% CI 0.41-0.65; p < 0.001).

Conclusion: One in three patients undergoing emergency intubation experienced a major peri-intubation adverse event, which was associated with higher 28-day mortality. These results underscore the importance of optimizing intubation strategies to reduce complications and potentially improve patient outcomes in critically ill patients.

Keywords: Adverse events; Airway registry; Critical illness; Difficult airway; Emergency airway management; Intubation.

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Conflict of interest statement

Declarations. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Enrollment flow diagram. *Others reasons for no inclusion intubations were “forgot to fill out”, “doesn’t remember completing”, or “invalid record number”). HR: Health Records; ICU: Intensive Care Unit
Fig. 2
Fig. 2
Association between the occurrence of major adverse events and 28-day mortality. HR: Hazard Ratio; OR: Odds Ratio; CI: Confidence Interval; MAE: Major Adverse Event; Major adverse events peri-intubation were defined as events during or thirty minutes after the intubation process, as listed below: hemodynamic Instability: Systolic Blood Pressure < 65 mmHg, need for starting or increase in vasopressor dose or fluid resuscitation; Severe hypoxemia: Oxygen peripheral saturation less than 80%; Cardiac arrest: Presence of cardiac arrest signs peri-intubation
Fig. 3
Fig. 3
Mortality rate by days after intubations, stratified by major adverse events. Patients who were discharged were considered alive through the 28-day follow-up period for this analysis
See this image and copyright information in PMC

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