Indications for Tracheal Intubation in Patients With Coronavirus Disease 2019 (COVID-19)

Abstract

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Semiquantitative Chest CT Severity Score Predicts Failure of Noninvasive Positive-Pressure Ventilation in Patients Hospitalized for COVID-19 Pneumonia

“…Optimal timing of OTI in patients with COVID-19 is still debated [28][29][30], where lung involvement by CT imaging might be considered as an adjunctive factor contributing to this evaluation [7]. Further studies are needed to fully assess whether a more prominent role of semi-quantitative chest CT evaluation in guiding ventilatory treatment approach, with early OTI in patients with major lung anatomical involvement, might be associated with improved prognosis.…”

“…Non-invasive positive pressure ventilation (NPPV) with continuous positive airway pressure or pressure support by helmet or facemask showed to be a reliable tool for treatment of COVID-19 patients even outside ICUs [2][3][4][5], being associated with substantial beneficial effect especially when used early during hospitalization [6]. On the other hand, the need for and timing of orotracheal intubation (OTI) and mechanical ventilation are still debated [7]. Identification of people with COVID-19 in which NPPV approach will fail is of paramount importance, since it can aid optimal timing for OTI [2] or conversely palliative measures when a do-not-intubate (DNI) indication is present and NPPV itself seems to be associated with lower efficacy [8].…”

Management of COVID-19 Patients in the Emergency Department

“…Indications for endotracheal intubation in patients with COVID-19 include airway protection; severe decompensated acidosis (pH < 7.2–7.25); severe hypoxemia (PaO 2 < 50 mmHg or SaO 2 < 90–92%) despite maximal noninvasive respiratory support; clinical signs of increased work of breathing and respiratory muscle fatigue, e.g., use of respiratory accessory muscles, paradoxical motion of the abdomen, and retraction of the intercostal spaces; signs of tissue hypoxia despite maximal noninvasive respiratory support; severe hemodynamic instability; and use of extracorporeal membrane oxygenation (ECMO) [ 74 ]. The decision to intubate involves judgement and should be individualized and based not only on the oxygenation status but also the degree of respiratory distress, based on a clinical evaluation of the work of breathing.…”

“…The PaO 2 /FiO 2 ratio is not a reliable marker in non-intubated patients receiving either conventional oxygen therapy or non-invasive ventilatory support because it is often underestimated since the FiO 2 varies widely due to several factors such as the patient’s ventilatory pattern or the presence of air leaks and it is often overestimated [ 74 ]. A low PaO 2 /FiO 2 ratio, prevention of clinical deterioration, and severity of chest CT findings do not justify per se tracheal intubation [ 74 ].…”

In-Hospital Mortality of COVID-19 Patients Treated with High-Flow Nasal Oxygen: Evaluation of Biomarkers and Development of the Novel Risk Score Model CROW-65

“…So far, the treatment approach for severe cases of COVID-19 has mostly consisted of mechanical ventilation (MV) and corresponding intensive care treatment [ 10 , 11 ]. Indications for intubation still mainly depend on the estimation of the attending clinician, and are very inconsistent among different centers [ 12 , 13 , 14 ]. Recently, an early intubation approach has also been proposed [ 15 ].…”