Background and AimProphylactic endotracheal intubation for airway protection prior to endoscopy for the management of severe upper gastrointestinal bleeding (UGIB) is controversial. The aim of this meta‐analysis is to examine the clinical outcomes and costs related to prophylactic endotracheal intubation compared to no intubation in UGIB.MethodsEMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were used to identify studies through June 2017. Data regarding mortality, total hospital and intensive care unit length of stay (LOS), pneumonia, and cardiovascular events were collected. The DerSimonian‐Laird random effects models were used to calculate the inverse variance‐based weighted, pooled treatment effect across studies.ResultsSeven studies (five manuscripts and two abstracts) were identified (5662 total patients). Prophylactic intubation conferred an increased risk of death (odds ratio [OR], 2.59, 95% confidence interval [CI]: 1.01–6.64), hospital LOS (mean difference, 0.96 days, 95% CI: 0.26–1.67), and pneumonia (OR 6.58, 95% CI: 4.91–8.81]) compared to endoscopy without intubation. The LOS‐related cost was greater when prophylactic intubation was performed ($9020 per patient, 95% CI: $6962–10 609) compared to when it was not performed ($7510 per patient, 95% CI: $6486–8432). There was no difference in risk of cardiovascular events after sensitivity analysis.ConclusionProphylactic intubation in severe UGIB is associated with a greater risk of pneumonia, LOS, death, and cost compared to endoscopy without intubation. Randomized trials examining this issue are warranted.