Impact of time to intubation on mortality and pulmonary sequelae in critically ill patients with COVID-19: a prospective cohort study

Abstract

Question We evaluated whether the time between first respiratory support and intubation of patients receiving invasive mechanical ventilation (IMV) due to COVID-19 was associated with mortality or pulmonary sequelae. Materials and methods Prospective cohort of critical COVID-19 patients on IMV. Patients were classified as early intubation if they were intubated within the first 48 h from the first respiratory support or delayed intubation if they were intubated later. Surviving patients were evaluated after hospital discharge. Results We included 205 patients (140 with early IMV and 65 with delayed IMV). The median [p25;p75] age was 63 [56.0; 70.0] years, and 74.1% were male. The survival analysis showed a significant increase in the risk of mortality in the delayed group with an adjusted hazard ratio (HR) of 2.45 (95% CI 1.29–4.65). The continuous predictor time to IMV showed a nonlinear association with the risk of in-hospital mortality. A multivariate mortality model showed that delay of IMV was a factor associated with mortality (HR of 2.40; 95% CI 1.42–4.1). During follow-up, patients in the delayed group showed a worse DLCO (mean difference of − 10.77 (95% CI − 18.40 to − 3.15), with a greater number of affected lobes (+ 1.51 [95% CI 0.89–2.13]) and a greater TSS (+ 4.35 [95% CI 2.41–6.27]) in the chest CT scan. Conclusions Among critically ill patients with COVID-19 who required IMV, the delay in intubation from the first respiratory support was associated with an increase in hospital mortality and worse pulmonary sequelae during follow-up.

Comfort During Non-invasive Ventilation

“…Patients with delayed onset of invasive ventilation have increased mortality and more severe pulmonary sequelae in terms of lung carbon monoxide diffusion capacity (DLCO) and radiological imaging ( 105 ). One possible explanation may be that maintaining patients with NIV when not appropriate can trigger patient self-induced lung injury (P-SILI) due to increased inspiratory efforts ( 105 ).…”

“…Patients with delayed onset of invasive ventilation have increased mortality and more severe pulmonary sequelae in terms of lung carbon monoxide diffusion capacity (DLCO) and radiological imaging ( 105 ). One possible explanation may be that maintaining patients with NIV when not appropriate can trigger patient self-induced lung injury (P-SILI) due to increased inspiratory efforts ( 105 ). Therefore, in addition to NIV comfort, it is of pivotal importance to monitor predictors of failure of NIV, i.e., no change or worsen in pH, blood gases, respiratory rate, and agitation ( 19 ), to early intervene with intubation and not worsen patients' prognosis.…”

Lung ultrasound response to awake prone positioning predicts the need for intubation in patients with COVID-19 induced acute hypoxemic respiratory failure: an observational study

“…Furthermore, we also found that the reduction in dorsal LUS score > 1 in the first APP session predicted the treatment success. Importantly, this finding can help early identify those patients with high risk of APP failure, who might benefit from more intensive monitoring and early treatment escalation and not delay intubation [ 21 ]. Thus, LUS assessment may be a very useful tool in the day-to-day clinical decision-making process.…”

The Impact of Different Ventilatory Strategies on Clinical Outcomes in Patients with COVID-19 Pneumonia

“…Invasive MV via a tracheal tube appears to be the most common approach after failed NIV but is associated with higher all-cause mortality in COVID-19 patients [ 10 , 11 , 12 ]. Contrasting results have been published regarding early intubation in terms of survival benefits [ 13 , 14 , 15 , 16 , 17 ]. Tracheostomy is considered an effective alternative to invasive MV via tracheal tube since it helps to reduce dead-space ventilation and decreases airway resistance and the risk of aspiration, as well as the need for sedation, facilitating weaning from a ventilator [ 18 ].…”