Sex differences in serious outcomes among critically ill adults following endotracheal intubation

Abstract

BACKGROUND

Several studies have reported sex differences in resuscitation outcomes in critically ill adults, but whether these differences are associated with endotracheal intubation practices is not known.

AIM

To investigate sex differences in serious outcomes among critically ill adults undergoing endotracheal intubation in the emergency department.

METHODS

In this observational study, we enrolled all critically ill adult patients who underwent endotracheal intubation in the emergency department from 2016 to 2020. The serious outcomes were defined as mortality within 1 hour post endotracheal intubation, cardiac arrest within 1 hour post intubation, worsening hypotension (systolic blood pressure < 90 mmHg) and oxygen desaturation (< 92%). Variables known or suspected to be associated with serious outcomes were examined with univariate logistic regression. Furthermore, we conducted sensitivity analysis on the patient cohort, incorporating propensity score matching with nearest neighbor methods at a ratio of 1:1 to address baseline variations between male and female participants, using R program software version 4.1.3 with a library (MatchIT).

RESULTS

A total of 1021 patients were enrolled in our study, with a median age of 52.2 years (± 17.5). The mean age of the females was 52.2 (± 17.8) years, and that of the males was 52.1 (± 17.3) years. Endotracheal intubation was most frequently observed in males (634; 62%). The frequency of cardiac arrest was 118 (18.6%) males and 77 (19.9%) females, with a P value of 0.612. Similarly, the frequency of hypotension (systolic blood pressure < 90 mmHg) was 225 (35.5%) in males and 154 (39.8%) in females (P = 0.167). This was followed by hypoxia (< 92%), with 85 (13.4%) males and 46 (11.9%) females, with a P value of 0.481. In total, 263 (41.5%) males died in the hospital, whereas 135 (39.1%) females died, P = 0.036. Severe outcomes were observed in 702 (68.8%) patients, 271 (70%) of whom were females, whereas 431 (68%) of whom were men (P = 0.494). After propensity score matching, postintubation hypotension was the most frequent serious event, observed in 304 (39.3%) patients, of whom 154 (39.8%) were females, whereas 150 (39.8%) were males (P = 0.001).

CONCLUSION

The study revealed that females were at greater risk of serious outcomes in critically ill adults post endotracheal intubation than males were in the emergency department.

Keywords: Sex; Serious outcomes; Emergency medicine; Airway; Predictors; Endotracheal intubation

Core Tip: This study explores sex-based differences in outcomes following endotracheal intubation in critically ill adults in the emergency department. Although overall complication rates were comparable between men and women, females demonstrated a higher incidence of post-intubation hypotension, even after adjustment for baseline clinical factors. This suggests that sex-related physiological differences may influence hemodynamic responses during airway management. The findings underscore the importance of recognizing sex as a potential risk modifier and highlight the need for tailored, sex-specific strategies to improve safety and optimize outcomes in critically ill patients undergoing intubation.