Abstract
Background The primary aim of our study was to investigate the association between intubation timing and hospital mortality in critically ill patients with coronavirus disease 2019 (COVID-19)-associated respiratory failure. We also analysed both the impact of such timing throughout the first four pandemic waves and the influence of prior noninvasive respiratory support on outcomes.
Methods This is a secondary analysis of a multicentre, observational and prospective cohort study that included all consecutive patients undergoing invasive mechanical ventilation due to COVID-19 from across 58 Spanish intensive care units (ICUs) participating in the CIBERESUCICOVID project. The study period was between 29 February 2020 and 31 August 2021. Early intubation was defined as that occurring within the first 24 h of ICU admission. Propensity score matching was used to achieve a balance across baseline variables between the early intubation cohort and those patients who were intubated after the first 24 h of ICU admission. Differences in outcomes between early and delayed intubation were also assessed. We performed sensitivity analyses to consider a different time-point (48 h from ICU admission) for early and delayed intubation.
Results Of the 2725 patients who received invasive mechanical ventilation, a total of 614 matched patients were included in the analysis (307 for each group). In the unmatched population, there were no differences in mortality between the early and delayed groups. After propensity score matching, patients with delayed intubation presented higher hospital mortality (27.3% versus 37.1%; p=0.01), ICU mortality (25.7% versus 36.1%; p=0.007) and 90-day mortality (30.9% versus 40.2%; p=0.02) compared with the early intubation group. Very similar findings were observed when we used a 48-h time-point for early or delayed intubation. The use of early intubation decreased after the first wave of the pandemic (72%, 49%, 46% and 45% in the first, second, third and fourth waves, respectively; first versus second, third and fourth waves p<0.001). In both the main and sensitivity analyses, hospital mortality was lower in patients receiving high-flow nasal cannula (HFNC) (n=294) who were intubated earlier. The subgroup of patients undergoing noninvasive ventilation (n=214) before intubation showed higher mortality when delayed intubation was set as that occurring after 48 h from ICU admission, but not when after 24 h.
Conclusions In patients with COVID-19 requiring invasive mechanical ventilation, delayed intubation was associated with a higher risk of hospital mortality. The use of early intubation significantly decreased throughout the course of the pandemic. Benefits of such an approach occurred more notably in patients who had received HFNC.
Abstract
In patients who require intubation and invasive mechanical ventilation due to COVID-19-associated acute respiratory failure, delays in implementation may increase the risk of mortality https://bit.ly/3fZLCIP
Footnotes
Individual members of the CIBERESUCICOVID group: Immaculada Salvador-Adell, Alexander Agrifoglio, María Aguilar Cabello, Luciano Aguilera, Victoria Alcaraz-Serrano, Cesar Aldecoa, Cynthia Alegre, Sergio Álvarez, Antonjo Álvarez Ruiz, Rut Andrea, José Ángel, Marta Arrieta, J. Ignacio Ayestarán, Joan Ramon Badia, Mariona Badía, Orville Báez Pravia, Ana Balan Mariño, Begoña Balsera, Laura Barbena, Tommaso Bardi, Patricia Barral Segade, Marta Barroso, José Ángel Berezo García, Judit Bigas, Rafael Blancas, María Luisa Blasco Cortés, María Boado, María Bodi Saera, Neus Bofill, María Teresa Bouza Vieiro, Leticia Bueno, Juan Bustamante-Munguira, Lucia Cachafeiro, David Campi Hermoso, Sandra Campos Fernández, Iosune Cano, Maria Luisa Cantón-Bulnes, Pablo Cardina Fernández, Laura Carrión García, Sula Carvalho, Núria Casacuberta-Barberà, Manuel Castellà, Andrea Castellví, Pedro Castro, Ramon Cicuendez Ávila, Catia Cillóniz, Luisa Clar, Cristina Climent, Jordi Codina, Pamela Conde, Sofía Contreras, María Cruz Martin, Raul de Pablo Sánchez, Diego De Mendoza, Cecilia del Busto Martínez, Yolanda Díaz, María Digna Rivas Vilas, Cristina Dólera Moreno, Irene Dot, Pedro Enríquez Giraudo, Inés Esmorís Arijón, Teresa Farre Monjo, Javier Fernández, Carlos Ferrando, Albert Figueras, Eva Forcadell-Ferreres, Lorena Forcelledo Espina, Nieves Franco, Àngels Furro, Felipe García, Beatriz García, Emilio García Prieto, Carlos García Redruello, Amaia García Sagastume, Maria Luisa Gascón Castillo, Gemma Gomà, Vanesa Gómez Casal, Silvia Gómez, Carmen Gómez Gonzalez, Jessica González, Federico Gordo, Maria Pilar Gracia, Alba Herraiz, Rubén Herrán-Monge, Mercedes Ibarz, Silvia Iglesias, Maria Teresa Janer, Gabriel Jiménez, Mar Juan Díaz, Karsa Kiarostami, Juan I. Lazo Álvarez, Miguel León, Alexandre López-Gavín, Ana López Lago, Desire Macias Guerrero, Nuria Mamolar Herrera, Rafael Mañez Mendiluce, Cecilia L. Mantellini, Gregorio Marco Naya, Pilar Marcos, Enrique Marmol Peis, Paula Martín Vicente, María Martínez, Carmen Eulalia Martínez Fernández, Maria Dolores Martínez Juan, Juan Fernando Masa Jimenez, Joan Ramon Masclans, Emilio Maseda, Eva María Menor Fernández, Mar Miralbés, Josman Monclou, Juan Carlos Montejo-González, Neus Montserrat, María Mora Aznar, Pedro Moral-Parras, Dulce Morales, Sara Guadalupe Moreno Cano, David Mosquera Rodríguez, Rosana Muñoz-Bermúdez, José María Nicolás, Ramon Nogue Bou, Rafaela Nogueras Salinas, Marta Ocón, Ana Ortega, Sergio Ossa, Pablo Pagliarani, Anna Parera Pous, Francisco Parrilla, Leire Pérez Bastida, Purificación Pérez, Gloria Pérez Planelles, Eva Pérez Rubio, David Pestaña Laguna, Esther Sauras-Colón, Javier Prados, Andrés Pujol, Núria Ramon Coll, Gloria Renedo Sanchez-Giron, Ferran Roche-Campo, Laura Rodriguez, Felipe Rodríguez de Castro, Silvia Rodríguez, Covadonga Rodríguez Ruiz, Jorge Rubio, Alberto Rubio López, Miriam Ruiz Miralles, Pablo Ryan Murúa, Eva Saborido Paz, Ana Salazar Degracia, Miguel Sanchez, Ana Sánchez, Bitor Santacoloma, Maria Teresa Sariñena, Marta Segura Pensado, Lidia Serra, Mireia Serra-Fortuny, Ainhoa Serrano Lázaro, Lluís Servià, Laura Soliva, Carla Speziale, Daniel Tognetti, Adrián Tormos, Mateu Torres, Sandra Trefler, Javier Trujillano, Alejandro Úbeda, Luis Urrelo-Cerrón, Estela Val, Luis Valdivia Ruiz, Montse Vallverdú, Maria Van der Hofstadt Martin-Montalvo, Sabela Vara Adrio, Nil Vázquez, Javier Vengoechea, Pablo Vidal Cortes, Clara Vilà-Vilardel, Judit Vilanova, Tatiana Villada Warrington, Hua Yang, Minlan Yang, Ana Zapatero and Jesús F. Bermejo-Martín.
Author contributions: A. Torres, J. Riera, E. Barbeta, A. Motos, L. Fernández-Barat and A. Ceccato participated in protocol development, study design, study management, statistical analysis and data interpretation. A. Tormos and D. García-Gasulla participated in statistical analysis and data interpretation. A. Palomeque, O. Peñuelas, J.Á. Lorente, C. Ferrando, R. Mellado-Artigas, F. Barbé and R. Ferrer participated in study design, study management and interpretation, and critical review of the first report draft. O. Roca participated in data interpretation and critical review of the manuscript. The CIBERESUCICOVID Consortium participated in data collection. All authors read and approved the final manuscript.
Conflicts of interest: O. Roca discloses a research grant from Hamilton Medical AG; speaker fees from Hamilton Medical AG, Ambu, Fisher & Paykel Ltd and Aerogen Ltd; and nonfinancial research support from Timpel and Masimo. R. Mellado-Artigas reports speaker fees from Medtronic and Fisher & Paykel, all outside the submitted work. The remaining authors declare no conflicts of interest.
Support statement: Financial support was provided by the Instituto de Salud Carlos III de Madrid (COV20/00110, ISCIII), Fondo Europeo de Desarrollo Regional (FEDER), “Una manera de hacer Europa” and the Centro de Investigación Biomedica En Red – Enfermedades Respiratorias (CIBERES). D. de Gonzalo-Calvo has received financial support from the Instituto de Salud Carlos III (Miguel Servet 2020: CP20/00041), co-funded by European Social Fund (ESF)/“Investing in Your Future”. Funding information for this article has been deposited with the Crossref Funder Registry.
- Received July 22, 2022.
- Accepted October 5, 2022.
- Copyright ©The authors 2023.
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