Intubation Timing vs Non-Intubation Management on the Outcomes of Patients with Respiratory Distress Secondary to COVID-19 Pneumonia

Document Type

Conference Proceeding

Publication Date

5-1-2021

Publication Title

Anesth Analg

Abstract

INTRODUCTION: As COVID-19 is a novel virus, there is very limited information available about the impact of different clinical treatment approaches on patient outcomes. The Chinese Society of Anesthesiology Task Force on Airway Management's initial recommendation was to proceed with endotracheal intubation1-2. Most experts with experience managing COVID-19 patients suggest early intubation. There is also limited evidence that late intubation has been associated with increased mortality in patients with adult respiratory distress syndrome3. The rationale for early intubation in patients with COVID-19 is that these patients can deteriorate rapidly to life threatening hypoxemia with limited time to deal with the logistical complexity of intubation, and disease progression may limit the ability to be effectively pre-oxygenate the patient. On the other hand, one could argue that patients with COVID-19 are at risk of ventilator-induced lung injury and that intubation should be avoided if at all possible. Mechanical ventilation increases the risk of many complications for example muscle weakness, delirium, ventilator associated pneumonia or even mortality. The purpose of this retrospective chart review is to evaluate whether the timing of intubation (early vs late), as well as use of intubation vs no intubation, leads to differences in outcomes in patients with severe ARDS secondary to COVID-19. METHODS: - Subject Population: All patients admitted to our facility between March 12th 2020 and December 15th 2020 with COVID-19 pneumonia that developed severe respiratory distress. - Enrollment and/or Screening: This is a retrospective chart review study. Participants were identified by searching in the EPIC electronic medical record database for a COVID-19 pneumonia diagnosis upon admission. - Inclusion Criteria: COVID-19 pneumonia with bilateral infiltrates on chest x-ray, with at least one of the following: Respiratory rate > 30 for 2 hours, and/or oxygen saturation <93% for 2 hours. - Exclusion Criteria: Patients with a “do not intubate” order. - Patients were be divided into 3 groups: • Early intubation group: Patients that were intubated within 24 hours of meeting inclusion criteria. • Late intubation group: Patients that were intubated after 24 hours of meeting inclusion criteria. • Nonintubated group: Patient that met inclusion criteria but were not intubated during hospital admission. - Number of patients enrolled in the study: 339. - Data measured: • Primary outcome: mortality. • Secondary outcome: ventilation days, ICU Days, hospital days, discharge disposition. • Age and SOFA (Sequential organ failure assessment) score. - Statistical method: Numeric variables were summarized with mean and standard deviation (SD) or median and interquartile range (IQR) and compared using ANOVA or Kruskal-Wallis test. Categorical variables were summarized with frequencies and proportions and compared using Chi-square test or fisher exact test. Post-hoc comparison will be conducted when appropriate. Adjusted p-values were reported for post-hoc multiple comparison. All tests will be two-sided. A p-value < 0.05 is considered statistically significant. RESULTS: On analysis of the results in 3 groups (table 1), there is statistically significant difference in mortality where non intubated patients had 9% mortality, compared to 43% in early intubation and 52% in late intubation (p value <0.001). Non intubated patient stayed in hospital for shorted duration (7 days, IQR 5, 11) compared to early intubation (18 days, IQR 10.5, 29.5) and late intubation (19 days IQR 14, 28.5) (p value < 0.001). Non intubated patients are more likely to be discharged home under self care (61%) compared to early (1.8 %) and late intubation (5%) (p value < 0.001). Subhoc analysis in early vs late intubation groups, there is statistical significant difference in SOFA score, but no statistical significant difference in mortality, ventilation days, ICU or hospital length of stay. CONCLUSION: Based on our results, we conclude that avoiding intubation i patients with COVID-19 pneumonia with respiratory distress without other organ involvement is associated with decreased overall mortality, hospital length of stay and patients were more likely to go home under self-care. In the patients who were intubated due to COVID-19 pneumonia, there was no statistical significant difference in outcomes regarding timing of intubation. (Table Presented).

Volume

132

Issue

5

First Page

350

Last Page

352

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