Purpose: Intubation is a common procedure in acute hypoxemic respiratory failure (AHRF), with minimal evidence to guide decision-making. We conducted a survey of when to intubate patients with AHRF to measure the influence of clinical variables on intubation decision-making and quantify variability. Methods: We developed an anonymous factorial vignette-based web survey to ask clinicians involved in the decision to intubate 'Would you recommend intubation?' Respondents selected an ordinal recommendation from a 5-point scale ranging from 'Definite no' to 'Definite yes' for up to 10 randomly allocated vignettes. We disseminated the survey through clinical and academic societies, analyzed responses using Bayesian proportional odds modeling with clustering by individual, country, and region, and reported mean odds ratios (OR) with 95% credible intervals (CrI). Results: Between September 2023 and January 2024, 2,294 respondents entered 17,235 vignette responses in 74 countries [most common: Canada (29%), USA (26%), France (9%), Japan (8%), and Thailand (5%)]. Respondents were attending physicians (63%), nurses (13%), trainee physicians (9%), respiratory therapists (9%), other (6%). Lower oxygen saturation, higher inspired oxygen fraction, non-invasive ventilation compared to high-flow, tachypnea, neck muscle use, abdominal paradox, drowsiness, and inability to obey were associated with increased odds of intubation; diagnosis, vasopressors, and duration of symptoms were not. Within a country the odds of recommending intubation changed between clinicians by an average factor of 2.60, while changing between countries within a region changed it by 1.56. Conclusion: In this international, interprofessional survey of more than 2000 practicing clinicians, intubation for patients with AHRF was mostly decided based on oxygenation, breathing pattern, and consciousness, but there was important variation across individuals and countries.

Dr Brochard's laboratory received grants from Medtronic, Stimit, Vitalaire, equipment from Philips, Sentec, Fisher Paykel, Cerebra Health. Dr Ricard Mellado-Artigas has received lecturing fees from Medtronic, MSD and Fisher and Paykel. Dr. Bellani receives lecturing fees from Draeger Medical and consultancy fees from Flowmeter.

https://osf.io/f7dsv/

Survey dissemination costs were covered by an Interdepartmental Division of Critical Care Medicine Trainee Award to Dr Yarnell. Dr Fowler is the H. Barrie Fairley Professor of Critical Care at the University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto. Funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; nor in the decision to submit the manuscript for publication. The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by any of the funding agencies is intended or should be inferred.

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