Timing of Intubation in Coronavirus Disease 2019: A Study of Ventilator Mechanics, Imaging, Findings, and Outcomes

Abstract

Objectives: Determine the variation in outcomes and respiratory mechanics between the subjects who are intubated earlier versus later in their coronavirus disease 2019 course. Design: Retrospective cohort study. Setting: Northwestern Memorial Hospital ICUs. Patients: All patients intubated for coronavirus disease 2019 between March 2020 and June 2020. Interventions: Patients were stratified by time to intubation: 30 subjects were intubated 4–24 hours after presentation and 24 subjects were intubated 5–10 days after presentation. Baseline characteristics, hospitalization, ventilator mechanics, and outcomes were extracted and analyzed. Ten clinically available CT scans were manually reviewed to identify evidence of pulmonary vascular thrombosis and intussusceptive angiogenesis. Measurements and Main Results: Median time from symptom onset to intubation was significantly different between the early and late intubation cohorts, with the latter being intubated later in the course of their illness (7.9 vs 11.8 d; p = 0.04). The early intubation cohort had a lower mortality rate than the late intubation cohort (6% vs 30%, p < 0.001) without significantly different respiratory mechanics at the time of intubation. The late intubation cohort was noted to have higher dead space ratio (0.40 vs 0.52; p = 0.03). On review of CT scans, the late intubation cohort also had more dilated peripheral segments on imaging (two segments vs five segments). Conclusions: The question as to whether delaying intubation is beneficial or harmful for patients with coronavirus disease 2019-induced hypoxemic respiratory failure has yet to be answered. As our approaches to coronavirus disease 2019 continue to evolve, the decision of timing of intubation remains paramount. Although noninvasive ventilation may allow for delaying intubation, it is possible that there are downstream effects of delayed intubation that should be considered, including the potential for pulmonary vascular thrombosis and intussusceptive angiogenesis with delayed intubation.

Comparison of clinical characteristics and outcomes of COVID-19 patients undergoing early versus late intubation from initial hospital admission: A systematic review and meta-analysis

“…BMI was similar for COVID-19 patients undergoing early intubation compared to those undergoing late intubation (mean 29.58 vs. 30.37 kg/m 2 ; MD -0.19; 95% CI [−2.51, 2.14]; I 2 = 80%; P = 0.87) ( Fig. 3 ) [ [5] , [6] , [7] , [8] , 12 , 13 ]. In three studies reporting the SOFA scores on admission, the early intubation group had higher score [mean 7.00 vs. 5.17; MD 1.87; 95% CI 0.99–2.75; I 2 = 58%; P < 0.001) than the late intubation group ( Fig.…”

Variations in end‐of‐life care practices in older critically ill patients with COVID‐19 in Europe

“…This is particularly interesting given the relatively similar median SOFA score, and may reflect different regional treatment strategies. When treating COVID‐19, the early or late use of MV—which allows the application of lung‐protective ventilation—and the optimal timing for tracheostomy are the subject of ongoing scientific and clinical debate [ 25 , 26 ]. As is well known, Italy, Spain, Portugal and Israel—all countries in Southern Europe—were hit hard relatively early in the COVID‐19 pandemic, and this may have affected how treatment was delivered.…”

Effect of Intubation Timing on the Outcome of Patients With Severe Respiratory Distress Secondary to COVID-19 Pneumonia

“…The synthesized evidence suggested that the timing of intubation based on ICU admission may have no effect on mortality or morbidity of critically ill patients with COVID-19 [9]. However, another study, which included 54 patients, looked at the timing of intubation based on hospital admission, where early intubation was defined as occurring between 4 and 24 hours from admission, while late intubation was defined as intubation from day five to day 10 of admission [10]. They found a mortality benefit in the early intubated group (10).…”

“…However, another study, which included 54 patients, looked at the timing of intubation based on hospital admission, where early intubation was defined as occurring between 4 and 24 hours from admission, while late intubation was defined as intubation from day five to day 10 of admission [10]. They found a mortality benefit in the early intubated group (10). Notably, none of the previous studies used the onset of respiratory distress as time zero for patient enrollment.…”