Early intubation versus late intubation for COVID-19 patients: An in situ simulation identifying factors affecting performance and infection control in airway management

Abstract

COVID-19 poses an infectious risk to healthcare workers especially during airway management. We compared the impact of early versus late intubation on infection control and performance in a randomised in situ simulation, using fluorescent powder as a surrogate for contamination. Twenty anaesthetists and intensivists intubated a simulated patient with COVID-19. The primary outcome was the degree of contamination. The secondary outcomes included the use of bag-valve-mask ventilation, the incidence of manikin cough, intubation time, first attempt success and heart rate variability as a measure of stress. The contamination score was significantly increased in the late intubation group, mean (standard deviation, SD) 17.20 (6.17), 95% confidence intervals (CI) 12.80 to 21.62 versus the early intubation group, mean (SD) 9.90 (5.13), 95% CI 6.23 to 13.57, P = 0.005. The contamination score was increased after simulated cough occurrence (mean (SD) 18.0 (5.09) versus 5.50 (2.10) in those without cough; P<0.001), and when first attempt laryngoscopy failed (mean (SD) of 17.1 (6.41) versus 11.6 (6.20) P = 0.038). The incidence of bag-mask ventilation was higher in the late intubation group (80% versus 30%; P=0.035). There was no significant difference in intubation time, incidence of failed first attempt laryngoscopy or heart rate variability between the two groups. Late intubation in patients with COVID-19 may be associated with greater laryngoscopist contamination and potential aerosol-generating events compared with early intubation. There was no difference in performance measured by intubation time and incidence of first attempt success. Late intubation, especially when resources are limited, may be a valid approach. However, strict infection control and appropriate personal protective equipment usage is recommended in such cases.

A Pilot Study on Electrical Impedance Tomography During CPAP Trial in Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Pneumonia: The Bright Side of Non-invasive Ventilation

“…Paradigmatic of this struggle is the amendments made by National COVID-19 Clinical Evidence Taskforce (NCCET) (Whang et al, 2021) that deleted the following statement from its revised guidelines "in patients with hypoxemia associated with COVID-19, do not routinely use NIV" (Whang et al, 2021). Since then, a number of studies dealt with the COVID-19 outcome prediction (Tseng et al, 2021), early vs. late intubation (Lee et al, 2021), and criteria for NIV and prediction of NIV failure Bellani et al, 2017;He et al, 2019), so that at present, the debate is still going and no definite recommendations are available, while patients are still largely ventilated with NIV, mainly in non-ICU departments and often by non-ICU trained physicians. An effort to provide clear and simple means to early discriminate patients that require intubation is thus needed, perhaps more due to ethical reasons than purely speculative ones.…”

“…Presently, an increasing amount of studies are reporting successful treatment of SARS-CoV-2 pneumonia in non-intubated patients, ventilated with moderate to high level of positive airways pressure (PEEP/CPAP) (8-12 cmH 2 O) and cycles of awake proning (Bamford et al, 2020;Whang et al, 2021). Accurate selection of patients, appropriate PEEP/CPAP setting, and correct timing for switching to invasive mechanical ventilation in non-responders to the non-invasive approach are thus of paramount importance and still remain among the most debated topics in the intensive care unit (ICU) environment and more (Lee et al, 2021;Tseng et al, 2021).…”

Does the intubation timeline affect the in-hospital mortality of COVID-19 patients? A retrospective cohort study

“…This resulted in an explicit supposition suggestion that COVID-19 patients be ventilated earlier in the illness course to avert lung impairment. Current evidence on COVID-19 treatment and consequences, however, has thrown this paradigm into doubt (12,13,21,(23)(24)(25). COVID-19 has different pathophysiology than more conventional ARDS and is more prone to non-invasive methods of ventilation such as high-flow nasal cannula (26).…”

“…In a meta-analysis, it was found no statistically detectable difference in all-cause mortality between patients undergoing early vs. late intubation (11). Studies have shown conflicting results based on treating patients infected with COVID-19 with early or late intubation, though shreds of evidence are still sparse as coronavirus is still active in its variant forms (12)(13)(14)(15). The compiled evidence indicates that intubation timings may not influence the COVID-19-related mortality and morbidity in critically ill cases (11).…”

The timing of intubation and principles of ICU care in COVID-19

“…On the other hand, delayed intubation might cause death. In a retrospective cohort study of critically ill patients related to COVID-19 pneumonia, Bavishi et al demonstrated that later intubation was associated with a higher mortality rate than early intubation, but they could not find a significant difference in parameters of lung mechanics related to worsening of ARDS [46]. Recently, some observational and retrospective studies indicated no significant difference between early, late or no intubation in mortality of critically ill COVID-19 patients with ARDS [47].…”