Does Endotracheal Intubation Reduce the Incidence of Cardiopulmonary Complications in Upper Gastrointestinal Bleeding?

At present, upper gastrointestinal (GI) endoscopy is considered a safe procedure with low complication rates. According to various studies, the estimated overall rates of complications varies between 0.6/1000 and 5.4/1000 procedures, with mortality rates ranging from 0.01/1000 to 0.4/1000 procedures.[1] However, serious cardiopulmonary complications, caused by aspiration of gastric contents and blood, may occur in patients presenting with upper GI bleeding. The upper GI endoscopy-related complication rates range from 1% to 8%, and the overall complication rate can reach 12–23%. Cardiopulmonary complications are estimated at 23–50% of all adverse events in patients with upper GI bleeding and are responsible for 50–60% of deaths.[2]

In other studies, the mortality rate of patients with nonvariceal GI bleeding has been reported to be 3.5–10%,[3] while in patients with variceal GI bleeding, mortality rates can reach 15–20%.[45] Prophylactic intubation is widely practiced in the Intensive Care Unit setting in cases of severe upper GI hemorrhage to protect the airways during the procedure, thereby decreasing the likelihood of expected cardiopulmonary complications.[6]

Aspiration of gastric contents and blood in patients with severe upper GI bleeding and in those subjected to upper GI endoscopy is considered one of the major complications. Another complication is lung infiltration, which can be seen radiologically in 4.8% of the patients within 4 h after the procedure.[7] In another large-scale study, a higher percentage of intubated patients (14%) developed pneumonia within 48 h after the procedure than nonintubated patients (2%).[7] The reason for this higher incidence of lung infiltrations in intubated patients is multifactorial, such as comorbid conditions: chronic liver disease and chronic renal and respiratory failures.[8910]

However, none of the reviewed studies showed any evidence that prophylactic endotracheal intubation decreases the incidence of cardiopulmonary complications. Based on the results of these studies, the benefits of prophylactic endotracheal intubation remain controversial, and thus, additional prospective studies are needed to determine if any subgroup of patients may benefit from endotracheal intubation during upper GI endoscopy in severe GI bleeding.