Fewer Intubations but Higher Mortality Among Intubated Coronavirus Disease 2019 Patients During the Second Than the First Wave

Abstract

OBJECTIVES: Since changes in pharmacological treatments for severely ill patients with coronavirus disease 2019 have been incorporated into clinical practice, both by their use (corticosteroids and remdesivir) and by stopping them (e.g., hydroxychloroquine), we sought to compare the rate of intubation and mortality of intubated patients in our ICUs between the first and second waves of the pandemic. DESIGN: Single-center, observational. SETTING: Four coronavirus disease 2019 designated ICUs at an urban Greek teaching hospital. PATIENTS: All adult patients with coronavirus disease 2019 consecutively admitted to ICU during the first ( n = 50) and second ( n = 212) waves of the pandemic. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The percentage of intubated ICU patients dropped from 82% during the first wave to 66% during the second wave ( p = 0.042). However, the absolute number of intubated ICU patients was lower during the first than the second wave (41 vs 140 patients). ICU or hospital mortality of intubated patients increased from 39% during the first wave to 60% during the second wave ( p = 0.028). The binary logistic regression for hospital mortality as the dependent variable in intubated patients and covariates the age, Acute Physiology and Chronic Health Evaluation II score, cardiovascular comorbidity, lactate, positive end-expiratory pressure, Sequential Organ Failure Assessment score, and wave, distinguished only Acute Physiology and Chronic Health Evaluation II (odds ratio, 1.40 with 95% CI, 1.14—1.72; p = 0.001) as the sole independent predictor of hospital mortality. CONCLUSIONS: Pharmacological adaptations and other measures may have led to fewer intubations over time. However, these changes do not seem to be translated into improved outcomes of intubated patients. Perhaps the same change in the use of drugs and protocols that could cause fewer intubations of ICU patients might be a reason of increased mortality in those patients who are eventually intubated. Furthermore, the relative staff inexperience and overall increase in patients’ comorbidities during the second wave could have contributed to increased Acute Physiology and Chronic Health Evaluation II score and mortality of intubated patients.

Changes over time in characteristics, resource use and outcomes among ICU patients with COVID‐19—A nationwide, observational study in Denmark

“…This may represent a change in the indications for the use of these invasive techniques in Danish ICUs. Similar trends have been observed in other hospitals, regions and countries 3–6,11 …”

“…Similar trends have been observed in other hospitals, regions and countries. [3][4][5][6]11 As for the use of invasive mechanical ventilation, there were likely early concerns about the safety of patients and staff of the use of open systems for oxygen supplementation.…”

“…2 There are reports on potential changes in characteristics, resource use and outcomes of ICU patients with COVID-19 between the first wave and subsequent time periods, but most studies are from single centres or regions. 3,4 Furthermore, the interpretation of the few nationwide studies is limited by lack of data on patient characteristics and resource use. 5,6 In addition, the periodic heavy strain on many healthcare systems has likely influenced the selection, use of organ support and outcomes of ICU patients, [7][8][9] no.…”

Rapidly improving acute respiratory distress syndrome in COVID-19: a multi-centre observational study

“…Finally, one could consider our reported ICU-mortality of above 50% for the combined cohort (and specifically above 80% among patients with persistent severe ARDS) as high. Indeed, although we had reported low mortality rate of intubated patients with COVID-19 in Greek ICUs during the first wave [ 28 ], we noticed an increase during the second wave [ 29 ]. During the second wave, patient load was high enough to put the Greek healthcare system (which admittedly had few reserves after years of underfunding due to a precedent long financial crisis) [ 30 ] at intermediate stress levels, when the availability of care was not nominally restricted but still adversely affected outcomes [ 31 ].…”

Effect of New Treatment Strategies of COVID-19 Intensive Care Unit Patients in the Second Wave and its Impact on Mortality

“…According to data from the Federal Institute for Hospital Charges, the proportion of mechanically ventilated patients decreased from 19% of all hospital patients with COVID-19 in the first wave to less than 8% in the second wave, or from 64% to 54% when treated in the intensive care unit [3]. In other hospitals, a decrease from 82% to 39% was reported [4]. In addition to changes in ventilation strategies, pharmacologic treatment also changed.…”