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Doing Less is Actually Doing More: The NICO Trial!

Individuals with reduced consciousness, commonly due to acute poisoning from substances like alcohol, drugs, or medication, face a notable risk of aspiration, potentially leading to respiratory complications, pneumonitis, and pneumonia. This condition often necessitates intubation, with over 20,000 cases annually in the U.S. alone. However, the decision to intubate in non-traumatic scenarios, particularly when the Glasgow Coma Scale (GCS) score is below 9, remains contentious. The presumed benefit of intubation is to prevent aspiration and subsequent pneumonia, but these are also major risks associated with the procedure itself. Other hazards include hemodynamic instability, hypoxia, difficult intubation, and dental damage. Current literature lacks robust evidence to definitively guide intubation decisions in comatose patients with acute poisoning, with some studies indicating early intubation might reduce aspiration risk, while others show no significant difference in aspiration or mortality rates.

To bridge this gap, the Non-invasive Airway Management of Comatose Poisoned Emergency Patients (NICO) trial was conducted. This randomized clinical trial aimed to determine whether avoiding intubation in comatose patients due to acute poisoning could lead to better outcomes compared to the conventional approach where intubation decisions are at the physician's discretion.

In a recent edition of the Journal of the American Medical Association (JAMA), the study conducted by Freund et al. offers a significant paradigm shift in the management of acute poisoning cases in emergency settings. The multicenter, randomized trial encompassed 225 patients, treated across 20 emergency departments and one intensive care unit, providing a robust and diverse sample size. These patients, with a mean age of 33 years, were in a state of reduced consciousness (obtunded or comatose) as indicated by a Glasgow Coma Scale (GCS) score of 8 or lower, primarily due to suspected poisoning, intoxication, or overdose. The predominant toxins involved were alcohol, identified in 66.7% of the cases, and benzodiazepines, accounting for 39.6%.

The Non-invasive Airway Management of Comatose Poisoned Emergency Patients (NICO) randomized clinical trial
The Non-invasive Airway Management of Comatose Poisoned Emergency Patients (NICO) randomized clinical trial

The study's findings are groundbreaking, particularly in its comparison between conventional care and a more conservative approach that avoids intubation in patients with a GCS score of 8 or less following acute poisoning. Remarkably, the conservative strategy not only proved to be safe but also significantly reduced the rates of intubation (57.8% to 16.4%), ICU admissions (66.1% to 39.7%), and adverse events (14.7% to 6.0%). It is important to note that patients requiring emergency intubation due to complications such as respiratory distress, oxygen desaturation, vomiting, or persistent shock were excluded from the study.

In summary, the study indicates that in cases of coma due to acute poisoning, a conservative airway management strategy could be more beneficial than routine intubation. This could lead to changes in clinical practice, emphasizing the need for careful patient evaluation and potential revision of existing intubation protocols in emergency and critical care settings.

What is your view on intubation in a patient with acute intoxication and a GCS of <9 at risk of aspiration?

  • 0%More inclined to intubate

  • 0%More inclined to hold intubation

  1. Freund Y, Viglino D, Cachanado M, et al. Effect of noninvasive airway management of comatose patients with acute poisoning: a randomized clinical trial.  JAMA. Published November 29, 2023. doi:10.1001/jama.2023.24391

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