Effects of intubation timing in patients with COVID-19 throughout the four waves of the pandemic: a matched analysis

Abstract

BackgroundThe primary aim of our study was to investigate the association between intubation timing and hospital mortality in critically ill patients with COVID-19-associated respiratory failure. We also analysed both the impact of such timing throughout the first four pandemic waves and the influence of prior non-invasive respiratory support on outcomes.MethodsThis is a secondary analysis of a multicentre, observational and prospective cohort study that included all consecutive patients undergoing invasive mechanical ventilation due to COVID-19 from across 58 Spanish intensive care units (ICU) participating in the CIBERESUCICOVID project. The study period was between 29 February 2020 and 31 August 2021. Early intubation was defined as that occurring within the first 24 h of intensive care unit (ICU) admission. Propensity score (PS) matching was used to achieve balance across baseline variables between the early intubation cohort and those patients who were intubated after the first 24 h of ICU admission. Differences in outcomes between early and delayed intubation were also assessed. We performed sensitivity analyses to consider a different timepoint (48 h from ICU admission) for early and delayed intubation.ResultsOf the 2725 patients who received invasive mechanical ventilation, a total of 614 matched patients were included in the analysis (307 for each group). In the unmatched population, there were no differences in mortality between the early and delayed groups. After PS matching, patients with delayed intubation presented higher hospital mortality (27.3%versus37.1%, p =0.01), ICU mortality (25.7%versus36.1%, p=0.007) and 90-day mortality (30.9%versus40.2%, p=0.02) when compared to the early intubation group. Very similar findings were observed when we used a 48-hour timepoint for early or delayed intubation. The use of early intubation decreased after the first wave of the pandemic (72%, 49%, 46% and 45% in the first, second, third and fourth wave, respectively; firstversussecond, third and fourth waves p<0.001). In both the main and sensitivity analyses, hospital mortality was lower in patients receiving high-flow nasal cannula (n=294) who were intubated earlier. The subgroup of patients undergoing NIV (n=214) before intubation showed higher mortality when delayed intubation was set as that occurring after 48 h from ICU admission, but not when after 24 h.ConclusionsIn patients with COVID-19 requiring invasive mechanical ventilation, delayed intubation was associated with a higher risk of hospital mortality. The use of early intubation significantly decreased throughout the course of the pandemic. Benefits of such an approach occurred more notably in patients who had received high-flow nasal cannula.

Unchanged Characteristics and Survival among Critically Ill COVID-19 Patients during First, Second, and Third Waves: A Prospective Observational Cohort

“…Supporting this clinical practice, a recent meta-analysis suggests that timing of intubation may have no effect on mortality and morbidity of critically ill patients with COVID-19 [48]. Other studies suggest contradictory results [49, 50]. Moreover, we did not compare ventilatory strategies or complications which would have influenced weaning from invasive MV [51].…”

New Guidelines for Severe Community-acquired Pneumonia

“…In a recent study, 67 HFNO showed an efficacy in reducing mortality compared with Noninvasive mechanical ventilation (NIMV) if associated with early intubation in patients with acute respiratory failure from SARS-CoV-2, but the latest 2023 ESICM guidelines about ARDS could not elaborate definitive recommendations due to this persistent lack of evidence. 68 Therefore, new clinical studies are needed to investigate differences in terms of mortality and intubation rate between groups of patients treated with HFNO and NIV.…”

Controversies Concerning Emergency Tracheal Intubation in Patients with COVID-19

“…The definitions of early and late intubation varied from previously temporal criteria to the current clinical classification based on the patient's clinical features before intubation. (Table 1) 30,32,[34][35][36][37][38][39] Therefore, there seems to be no concise intubation timing. The ROX index (SpO 2 /FiO 2 /breathing frequency), PaO 2 / FiO 2 ratio, and other clinical features, such as respiratory rate and hemodynamics, were recommended as indications for intubation.…”