Early intubation and decreased in-hospital mortality in patients with coronavirus disease 2019

Abstract

Background Some academic organizations recommended that physicians intubate patients with COVID-19 with a relatively lower threshold of oxygen usage particularly in the early phase of pandemic. We aimed to elucidate whether early intubation is associated with decreased in-hospital mortality among patients with novel coronavirus disease 2019 (COVID-19) who required intubation. Methods A multicenter, retrospective, observational study was conducted at 66 hospitals in Japan where patients with moderate-to-severe COVID-19 were treated between January and September 2020. Patients who were diagnosed as COVID-19 with a positive reverse-transcription polymerase chain reaction test and intubated during admission were included. Early intubation was defined as intubation conducted in the setting of ≤ 6 L/min of oxygen usage. In-hospital mortality was compared between patients with early and non-early intubation. Inverse probability weighting analyses with propensity scores were performed to adjust patient demographics, comorbidities, hemodynamic status on admission and time at intubation, medications before intubation, severity of COVID-19, and institution characteristics. Subgroup analyses were conducted on the basis of age, severity of hypoxemia at intubation, and days from admission to intubation. Results Among 412 patients eligible for the study, 110 underwent early intubation. In-hospital mortality was lower in patients with early intubation than those with non-early intubation (18 [16.4%] vs. 88 [29.1%]; odds ratio, 0.48 [95% confidence interval 0.27–0.84]; p = 0.009, and adjusted odds ratio, 0.28 [95% confidence interval 0.19–0.42]; p < 0.001). The beneficial effects of early intubation were observed regardless of age and severity of hypoxemia at time of intubation; however, early intubation was associated with lower in-hospital mortality only among patients who were intubated later than 2 days after admission. Conclusions Early intubation in the setting of ≤ 6 L/min of oxygen usage was associated with decreased in-hospital mortality among patients with COVID-19 who required intubation. Trial Registration None.

Early symptoms preceding post-infectious irritable bowel syndrome following COVID-19: a retrospective observational study incorporating daily gastrointestinal symptoms

“…Several patients with COVID-19 were identified in Japan in early 2020; thereafter, five surges of COVID-19 cases occurred in the study period. During these surges, the governor of Tokyo Metropolis announced several stay-at-home orders, each lasting for 1–2 months [ 18 ]. At the study institution, patients with mild-to-moderate COVID-19 who required oxygen, but not mechanical ventilation (MV), were treated by pulmonary internal medicine physicians in general wards, whereas intensive care physicians treated patients with severe COVID-19 who needed MV or extracorporeal membrane oxygenation in the intensive care unit (ICU).…”

Controversies Concerning Emergency Tracheal Intubation in Patients with COVID-19

“…It has been recommended to intubate COVID-19 patients earlier in disease progression. 29,30 Delayed intubation causes self-inflicted lung injury 31 and is associated with mortality in patients with severe COVID-19. 32 However, some other studies did not favor early intubation.…”

“…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.…”

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

“…The failure of "very early" intubation at the outset of the pandemic, and the subsequent overestimated mortality from using IMV, likely led to significantly increased use of NIV and HFNO for longer durations to avoid intubation. However, accumulating evidence suggests "delaying" intubation in patients with COVID-19-associated respiratory failure is also associated with a higher mortality (21)(22)(23)(24)(25). In a cohort of 574 ICU patients with COVID-19, "very late" intubation (beyond 5 d of HFNO or NIV initiation) had Commentary the rate of mortality (87%) (26).…”