Timing of Intubation in COVID-19 Patients: Early or Late?

The pendulum has swung when it comes to deciding when to proceed with intubation of our COVID-19 patients when it comes to timing. The early data suggested early intubation was the way to go as we were all terrified or aerosolization of the virus caused by the high-flow nasal oxygen or different modes of non-invasive ventilation (BPAP or CPAP). We quickly learned that this was a recipe for running out of ventilators early. Little by little we became more open to using these other modalities to the point where some have asked if we are waiting too long with regards to the timing of intubation. Are we allowing the lungs to be trashed by delaying intubation and therefore allowing them to be fibrosed? We all have the clinical question of when should we be intubating COVID-19 patients. Are we waiting too long? Are we doing it too soon? Does it even matter because those who have the significant underlying risk factors are going to reach their demise regardless of our interventions? ADDENDUM: FOR THE ARTICLE SHARED ON SOCIAL MEDIA ON 4/4/22, CHECK OUT THE CITATIONS TO DOWNLOAD IT.

This systematic review and meta-analysis is the best information that we have to date to help us guide management of these patients. One thing that we have to consider, however, is that there appears to be no randomized controlled trials looking at this. Therefore, the authors had to use non-randomized cohort studies. This is definitely a limitation to this meta-analysis but, it’s the best we have. All in all, they were able to collect 12 studies that involved a total of 8944 patients. Obviously, all these patients had COVID-19. All these data were observational.

They were able to break up the patients in early versus late intubation groups. The main question that you and I have is, what defines way early intubation is and what defines what late intubation is. In the study, the authors to find early intubation as “intubation within 24 hours from admission in the intensive care unit”. Late intubation was defined as “intubation at anytime after 24 hours of ICU admission”. This is where I struggle a bit with these types of studies simply because it does not help us define outcomes on patients in whom we wait seven days or even 14 days after admission to the hospital to go ahead and place them on mechanical ventilation.

The authors conducted their statistical jumping jacks and found that the “timing of intubation may have no effect on mortality and morbidity”. They also state that “these results might justify a wait-and-see approach”. There was no statistically significant difference on all-cause mortality, duration of mechanical ventilation, ICU length of stay, and need for renal replacement therapy. I definitely want to tip my hat to the authors because they made the best with the available data to conduct a meta-analysis. This is not a personal criticism of them but I do not feel that this is helpful, though. The reason for this is because there are still so many things that we do not know. And example of this is the question of how long were the patients in the hospital prior to transfer to the ICU? In my clinical practice, patients are in the step down unit for several days or even longer on high-flow nasal cannula prior to their clinical deterioration leading to transfer to the ICU. These data prove to not reflect how long the patients were just lounging in the rest of the hospital prior to ICU transfer.

It is my opinion that the more pressing question is does keeping the patients on high-flow nasal cannula until they tire out prove to be beneficial over simply placing them on mechanical ventilation. Does their clinical decline happen because of us? In my practice, I am using the ROX score to help me determine whether a patient needs to be intubated or not. I have covered the ROX index on several occasions in the past. CLICK HERE for that info. It would be nice if they performed subgroup analyses of outcomes if the patients were intubated on day 3, 7, 10, 14 of their hospital stay. It’s hard to criticize this because at the end of the day I could use the data from my own hospital system to publish these data but I don’t. That’s on me. We can all do better, I guess.

Citations regarding Intubation Timing:

Papoutsi E, Giannakoulis VG, Xourgia E, Routsi C, Kotanidou A, Siempos II. Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: a systematic review and meta-analysis of non-randomized cohort studies. Crit Care. 2021 Mar 25;25(1):121. doi: 10.1186/s13054-021-03540-6. PMID: 33766109.
Link to Article

Update on 4/4/22
Camous L, Pommier JD, Martino F, Tressieres B, Demoule A, Valette M. Very late intubation in COVID-19 patients: a forgotten prognosis factor? Crit Care. 2022 Apr 2;26(1):89. doi: 10.1186/s13054-022-03966-6. PMID: 35366941.
Link to Article

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