Timing of Intubation in COVID-19: When It Is Too Early and When It Is Too Late

Abstract

The timing of initiating mechanical ventilation in patients with acute respiratory distress syndrome due to COVID-19 remains controversial. At the outset of the pandemic, "very early" intubation was recommended in patients requiring oxygen flows above 6 L per minute but was followed closely thereafter by avoidance of invasive mechanical ventilation (IMV) due to a perceived (yet overestimated) risk of mortality after intubation. While the use of noninvasive methods of oxygen delivery, such as high-flow nasal oxygen (HFNO) or noninvasive positive pressure ventilation (NIV), can avert the need for mechanical ventilation in some, accumulating evidence suggests delayed intubation is also associated with an increased mortality in a subset of COVID-19 patients. Close monitoring is necessary in COVID-19 patients on HFNO or NIV to identify signs of noninvasive failure and ensure appropriate provision of IMV.

Effect of noninvasive ventilation on mortality and clinical outcomes among patients with severe hypoxemic COVID-19 pneumonia after high-flow nasal oxygen failure: a multicenter retrospective French cohort with propensity score analysis

“…However, the question of the ideal timing for intubation remains unresolved [ 28 – 30 ]. To sum up, mortality appears to be higher when either a “very early” or a “very delayed” intubation strategy is used [ 31 ].…”

The Respiratory Mechanics of COVID-19 Acute Respiratory Distress Syndrome—Lessons Learned?

“…One might consider this group of patients to have been in the very early intubation group of the Manrique study [24] that had poorer outcomes than their later counterparts. Taken together, the evidence points to an optimal period for intubation benefitting those patients whose respiratory insufficiency continues to go unresolved or show a negative trend [27].…”

A comparison study of temporal trends of SARS-CoV2 RNAemia and biomarkers to predict success and failure of high flow oxygen therapy among patients with moderate to severe COVID-19

“…In the early stages of the pandemic, it was recommended to intubate patients with COVID-19 very early when their oxygen requirements exceeded 6L/min, primarily as a measure to prevent the spread of the virus [ 1 , 2 ]. However, subsequent evidence regarding the potential benefits of high-flow nasal cannula (HFNC) oxygen therapy and non-invasive mechanical ventilation, coupled with concerns about the potential harm caused by premature unnecessary intubation, have raised questions regarding the very early intubation strategy [ 3 , 5 ]. Meanwhile, a meta-analysis including 20 non-randomized controlled studies revealed higher in-hospital mortality in patients that were intubated 24–48 hours or later after admission [ 8 ].…”