Timing of Invasive Mechanical Ventilation and Mortality among Patients with Severe COVID-19-associated Acute Respiratory Distress Syndrome
Anand M Tiwari, Sushma K Gurav, Prasad B Suryawanshi, Prajkta P Wankhede, Upendrakumar S Kapse, Abhaya P Bhoyar, Afroz Z Khan, Ria V Malhotra, Pranoti H Kusalkar, Kaustubh J Chavan, Seema A Naik, Rahul B Bhalke, Ninad N Bhosale, Sonika V Makhija, Venkata N Kuchimanchi, Amol S Jadhav, Kedar R Deshmukh, Gaurav S Kulkarni
Background: Severe acute respiratory distress syndrome associated with coronavirus disease-2019 (COVID-19) (CARDS) pneumonitis presents a clinical challenge as regards to the timing of intubation and ambiguity of outcome. There is a lack of clear consensus on when to switch patients from trials of noninvasive therapies to invasive mechanical ventilation. We investigated the effect of the timing of intubation from the time of admission on the clinical outcome of CARDS.
Aim and objective: The aim and objective was to analyze the effect of timing of intubation early (within 48 hours of admission to critical care unit) versus delayed (after 48 hours of admission to critical care unit) on mortality in severe CARDS patients.
Materials and methods: A retrospective observational study performed in a 28-bedded COVID-19 intensive care unit of a tertiary care hospital in Pune, India. All patients admitted between April 1, 2020, and October 15, 2020, with confirmed COVID-19 (RT-PCR positive) requiring mechanical ventilation were included in the study.
Results: The primary outcome was in-hospital mortality. Among 2,230 patients that were admitted to the hospital, 525 required critical care (23.5%), invasive mechanical ventilation was needed in 162 patients and 147 (28%) of critical care admission were included in the study cohort after exclusion. Seventy-five patients (51%) were intubated within 48 hours of critical care admission (early group) and 72 (48.9%) were intubated after 48 hours of critical care admission (delayed group). With regards to the total of 147 included patients; male patients were 74.1% with a median age of 59 years (interquartile range, 51–68 years). Diabetes (44.9%) and hypertension (43.5%) were the most common comorbidities. Higher admission acute physiology and chronic health evaluation II scores and lower absolute lymphocyte count were observed in patients intubated within 48 hours. The early intubated group had a mortality of 60% whereas the same was observed as 77.7% in delayed intubation group, and this difference was statistically significant (p = 0.02).
Conclusion: Current study concludes that early intubation is associated with improved survival rates in severe CARDS patients.
Contini C, Di Nuzzo M, Barp N, Bonazza A, De Giorgio R, Tognon M, et al. The novel zoonotic COVID-19 pandemic: an expected global health concern. J Infect Dev Ctries 2020;14(3):254–264. DOI: 10.3855/jidc.12671.
Sun P, Qie S, Liu Z, Ren J, Li K, Xi J. Clinical characteristics of hospitalized patients with SARS-CoV-2 infection: a single arm meta‐analysis. J Med Virol 2020;92(6):612–617. DOI: 10.1002/jmv.25735.
Windisch W, Weber-Carstens S, Kluge S, Rossaint R, Welte T, Karagiannidis C. Invasive and non-invasive ventilation in patients with COVID-19. Dtsch Ärztebl Int 2020;117(31–32):528. DOI: 10.3238/arztebl.2020.0528.
Matta SK. Dilemmas in Covid-19 respiratory distress: early vs late intubation; high tidal volume and low PEEP vs traditional approach? J Intensive Crit Care 2020;6(2):7. DOI: 10.36648/2471-8505.6.2.7.
Dhont S, Derom E, Van Braeckel E, Depuydt P, Lambrecht BN. The pathophysiology of ‘happy’ hypoxemia in COVID-19. Respir Res 2020;21(1):1-9. 10.1186/s12931-020-01462-5.
Navas-Blanco JR, Dudaryk R. Management of respiratory distress syndrome due to COVID-19 infection. BMC Anesthesiol 2020;20(1):1–6. DOI: 10.1186/s12871-020-01095-7.
Xie J, Tong Z, Guan X, Du B, Qiu H, Slutsky AS. Critical care crisis and some recommendations during the COVID-19 epidemic in China. Intensive Care Med 2020;1–4. DOI: 10.1007/s00134-020-05979-7.
Tobin MJ, Laghi F, Jubran A. Why COVID-19 silent hypoxemia is baffling to physicians. Am J Respir Crit Care Med 2020;202(3):356-60. DOI: 10.1164/rccm.202006-2157CP.
Wilkerson RG, Adler JD, Shah NG, Brown R. Silent hypoxia: a harbinger of clinical deterioration in patients with COVID-19. Am J Emerg Med 2020;38(10):2243.e5–2243.e6. DOI: 10.1016/j.ajem.2020.05.044.
Allali G, Marti C, Grosgurin O, Morélot-Panzini C, Similowski T, Adler D. Dyspnea: the vanished warning symptom of COVID-19 pneumonia. J Med Virol 2020. DOI: 10.1002/jmv.26172.
Li X, Ma X. Acute respiratory failure in COVID-19: is it “typical” ARDS? Critical Care 2020;24:1–5. DOI: 10.1186/s13054-020-02911-9.
Guan L, Zhou L, Le Grange JM, Zheng Z, Chen R. Non-invasive ventilation in the treatment of early hypoxemic respiratory failure caused by COVID-19: considering nasal CPAP as the first choice. Crit Care 2020;24(1):1–2. DOI: 10.1186/s13054-020-03054-7.
Tobin MJ, Laghi F, Jubran A. Caution about early intubation and mechanical ventilation in COVID-19. Ann Intensive Care 2020;10(1):1–3. DOI: 10.1186/s13613-020-00692-6.
Meng L, Qiu H, Wan L, Ai Y, Xue Z, Guo Q, et al. Intubation and ventilation amid the COVID-19 outbreak: Wuhan's experience. Anesthesiology. 2020;132(6):1317–1332. DOI: 10.1097/ALN.0000000000003296.
Lee YH, Choi KJ, Choi SH, Lee SY, Kim KC, Kim EJ, et al. Clinical significance of timing of intubation in critically ill patients with COVID-19: a multi-center retrospective study. J Clin Med 2020;9(9):2847. DOI: 10.3390/jcm9092847.
https://www.socscistatistics.com/tests/ (Accessed on 06/12/2020 at 14.33 IST) (5).
Wunsch H. Mechanical ventilation in COVID-19: interpreting the current epidemiology. Am J Respir Crit Care Med 2020;202(1):1–4. DOI: 10.1164/rccm.202004-1385ED.
Wang Y, Lu X, Li Y, Chen H, Chen T, Su N, et al. Clinical course and outcomes of 344 intensive care patients with COVID-19. Am J Respir Crit Care Med 2020;201(11):1430–1434. DOI: 10.1164/rccm.202003-0736LE.
Li LQ, Huang T, Wang YQ, Wang ZP, Liang Y, Huang TB, et al. COVID-19 patients’ clinical characteristics, discharge rate, and fatality rate of meta-analysis. J Med Virol 2020;92(6):577–583. DOI: 10.1002/jmv.25757.
Palaiodimos L, Kokkinidis DG, Li W, Karamanis D, Ognibene J, Arora S, et al. Severe obesity, increasing age and male sex are independently associated with worse in-hospital outcomes, and higher in-hospital mortality, in a cohort of patients with COVID-19 in the Bronx, New York. Metabolism 2020;108:154262. DOI: 10.1016/j.metabol.2020.154262.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395(10229):1054–1062. DOI: 10.1016/S0140-6736(20)30566-3.
Wu C, Chen X, Cai Y, Zhou X, Xu S, Huang H, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020;180(7):934–943. DOI: 10.1001/jamainternmed.2020.0994.
Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA 2020;323(20):2052–2059. DOI: 10.1001/jama.2020.6775.
Fan G, Tu C, Zhou F, Liu Z, Wang Y, Song B, et al. Comparison of severity scores for COVID-19 patients with pneumonia: a retrospective study. Eur Respir J 2020;56(3):2002113. DOI:10.1183/13993003.02113-2020.
Ferrando C, Mellado-Artigas R, Gea A, Arruti E, Aldecoa C, Bordell A, et al. Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: a prospective, cohort, multicentre study. Rev Esp Anestesiol Reanim 2020;67(8):425–437. DOI: 10.1016/j.redar.2020.07.003.
Yao Q, Wang P, Wang X, Qie G, Meng M, Tong X, et al. Retrospective study of risk factors for severe SARS-Cov-2 infections in hospitalized adult patients. Pol Arch Intern Med 2020;130(5):390–399. DOI: 10.20452/pamw.15312.
Fan BE, Chong VC, Chan SS, Lim GH, Lim KG, Tan GB, et al. Hematologic parameters in patients with COVID-19 infection. Am J Hematol 2020;95(6):E131–E134. DOI: 10.1002/ajh.25774.
Yang X, Yu Y, Xu J, Shu H, Liu H, Wu Y, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020;8(5):P475–P481. DOI: 10.1016/S2213-2600(20)30079-5.
Zou X, Li S, Fang M, Hu M, Bian Y, Ling J, et al. Acute physiology and chronic health evaluation II score as a predictor of hospital mortality in patients of coronavirus disease 2019. Crit Care Med 2020;48(8):e657–e665. DOI: 10.1097/CCM.0000000000004411.
Chen YT, Shao SC, Hsu CK, Wu IW, Hung MJ, Chen YC. Incidence of acute kidney injury in COVID-19 infection: a systematic review and meta-analysis. Crit Care 2020;24(1):1–4. DOI: 10.1186/s13054-020-03009-y.
Ronco C, Reis T, Husain-Syed F. Management of acute kidney injury in patients with COVID-19. Lancet Respir Med 2020;8(7):P738–P742. DOI: 10.1016/S2213-2600(20)30229-0.
Cox MJ, Loman N, Bogaert D, O’grady J. Co-infections: potentially lethal and unexplored in COVID-19. Lancet Microbe 2020;1(1):e11. DOI: 10.1016/S2666-5247(20)30009-4.
Piazza C, Filauro M, Dikkers FG, Nouraei SR, Sandu K, Sittel C, et al. Long-term intubation and high rate of tracheostomy in COVID-19 patients might determine an unprecedented increase of airway stenoses: a call to action from the European Laryngological Society. Eur Arch Otorhinolaryngol 2020:1–7. DOI: 10.1007/s00405-020-06112-6.
Lansbury L, Lim B, Baskaran V, Lim WS. Co-infections in people with COVID-19: a systematic review and meta-analysis. J Infect 2020;81(2):266–275. DOI: 10.1016/j.jinf.2020.05.046.
Zhang H, Zhang Y, Wu J, Li Y, Zhou X, Li X, et al. Risks and features of secondary infections in severe and critical ill COVID-19 patients. Emerg Microbes Infect 2020;9(1):1958–1964. DOI: 10.1080/22221751.2020.1812437.
Chaddha U, Kaul V, Agrawal A. What is the true mortality in the critically ill patients with COVID-19? Indian J Crit Care Med 2020;24(6):38. DOI: 10.5005/jp-journals-10071-23435.
Hyman JB, Leibner ES, Tandon P, Egorova NN, Bassily-Marcus A, Kohli-Seth R, et al. Timing of intubation and in-hospital mortality in patients with coronavirus disease 2019. Crit Care Explor 2020;2(10). DOI: 10.1097/CCE.0000000000000254.
Hernandez-Romieu AC, Adelman MW, Hockstein MA, Robichaux CJ, Edwards JA, Fazio JC, et al. Timing of intubation and mortality among critically Ill coronavirus disease 2019 patients: a single-center cohort study. Crit Care Med 2020;48(11):e1045–e1053. DOI: 10.1097/CCM.0000000000004600.
Kangelaris KN, Ware LB, Wang CY, Janz DR, Hanjing Z, Matthay MA, et al. Timing of intubation and clinical outcomes in adults with ARDS. Crit Care Med 2016;44(1):120. DOI: 10.1097/CCM.0000000000001359.