Article, 2024

Intubation Decision Based on Illness Severity and Mortality in COVID-19: An International Study*

Critical Care Medicine, ISSN 1530-0293, 0090-3493, Volume 52, 6, Pages 930-941, 10.1097/ccm.0000000000006229

Contributors

Chalkias, Athanasios F 0000-0002-7634-4665 (Corresponding author) [1] [2] Huang, Yiyuan [3] Ismail, Anis [3] Pantazopoulos, Ioannis N 0000-0002-8846-519X [4] Papagiannakis, Nikolaos 0000-0002-8401-8472 [4] Bitterman, Brayden A [3] Anderson, Elizabeth [3] Catalan, Tonimarie C [3] Erne, Grace K 0000-0003-1236-3901 [3] Tilley, Caroline R. [3] Alaka, Abiola A [3] Amadi, Kingsley M. [3] Presswalla, Feriel K 0000-0001-7190-5622 [3] Blakely, Pennelope [3] Bernal-Morell, Enrique 0009-0001-1753-9104 [5] López, Iria Cebreiros [6] Eugen-Olsen, Jesper 0000-0002-4630-4275 [7] De Guadiana-Romualdo, Luis García 0000-0003-3028-3198 [8] Giamarellos-Bourboulis, Evangelos J 0000-0003-4713-3911 [9] Loosen, Sven Heiko 0000-0002-2799-2287 [10] Reiser, Jochen [11] Tacke, Frank 0000-0001-6206-0226 [12] Skoulakis, Anargyros [4] Laou, Eleni [4] Banerjee, Mousumi [3] Pop-Busui, Rodica 0000-0002-2042-1350 [3] Hayek, Salim S. [3] Group, on behalf of the International Study of Inflammation in COVID-19 Investigator

Affiliations

  1. [1] Outcomes Research Consortium
    2. [NORA names: United States; America, North; OECD];
  2. [2] University of Pennsylvania
    3. [NORA names: United States; America, North; OECD];
  3. [3] University of Michigan–Ann Arbor
    4. [NORA names: United States; America, North; OECD];
  4. [4] University of Thessaly
    5. [NORA names: Greece; Europe, EU; OECD];
  5. [5] Hospital Reina Sofía de Murcia
    6. [NORA names: Spain; Europe, EU; OECD];

Abstract

OBJECTIVES: To evaluate the impact of intubation timing, guided by severity criteria, on mortality in critically ill COVID-19 patients, amidst existing uncertainties regarding optimal intubation practices. DESIGN: Prospective, multicenter, observational study conducted from February 1, 2020, to November 1, 2022. SETTING: Ten academic institutions in the United States and Europe. PATIENTS: Adults (≥ 18 yr old) confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hospitalized specifically for COVID-19, requiring intubation postadmission. Exclusion criteria included patients hospitalized for non-COVID-19 reasons despite a positive SARS-CoV-2 test. INTERVENTIONS: Early invasive mechanical ventilation (EIMV) was defined as intubation in patients with less severe organ dysfunction (Sequential Organ Failure Assessment [SOFA] < 7 or Pa o2 /F io2 ratio > 250), whereas late invasive mechanical ventilation (LIMV) was defined as intubation in patients with SOFA greater than or equal to 7 and Pa o2 /F io2 ratio less than or equal to 250. MEASUREMENTS AND MAIN RESULTS: The primary outcome was mortality within 30 days of hospital admission. Among 4464 patients, 854 (19.1%) required mechanical ventilation (mean age 60 yr, 61.7% male, 19.3% Black). Of those, 621 (72.7%) were categorized in the EIMV group and 233 (27.3%) in the LIMV group. Death within 30 days after admission occurred in 278 patients (42.2%) in the EIMV and 88 patients (46.6%) in the LIMV group ( p = 0.28). An inverse probability-of-treatment weighting analysis revealed a statistically significant association with mortality, with patients in the EIMV group being 32% less likely to die either within 30 days of admission (adjusted hazard ratio [HR] 0.68; 95% CI, 0.52-0.90; p = 0.008) or within 30 days after intubation irrespective of its timing from admission (adjusted HR 0.70; 95% CI, 0.51-0.90; p = 0.006). CONCLUSIONS: In severe COVID-19 cases, an early intubation strategy, guided by specific severity criteria, is associated with a reduced risk of death. These findings underscore the importance of timely intervention based on objective severity assessments.

Keywords

COVID-19, COVID-19 cases, COVID-19 patients, Early, Europe, LIMV, SARS-CoV-2 testing, SOFA, United States, academic institutions, acute respiratory syndrome coronavirus 2, admission, adults, analysis, assessment, associated with mortality, cases, coronavirus 2, criteria, critically ill COVID-19 patients, criticism, day of admission, days, days of hospital admission, death, decision, dysfunction, early invasive mechanical ventilation, exclusion, exclusion criteria, findings, group, hospital admission, ill COVID-19 patients, illness, illness severity, impact, institutions, intervention, intubation, intubation decisions, intubation practices, intubation strategies, intubation time, invasive mechanical ventilation, mechanical ventilation, mortality, multicenter, non-COVID-19, non-COVID-19 reasons, observational study, organ dysfunction, outcomes, patients, positive SARS-CoV-2 test, postadmission, practice, primary outcome, ratio, reasons, reduced risk, reduced risk of death, respiratory syndrome coronavirus 2, risk of death, severe COVID-19 cases, severe acute respiratory syndrome coronavirus 2, severe organ dysfunction, severity, severity assessment, severity criteria, state, statistically, statistically significant association with mortality, strategies, study, syndrome coronavirus 2, test, time, uncertainty, units, ventilation, weight analysis

Funders

  • National Institute of Diabetes and Digestive and Kidney Diseases

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