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Meta-Analysis
. 2021 Mar 25;25(1):121.
doi: 10.1186/s13054-021-03540-6.

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

Eleni Papoutsi #  1 , Vassilis G Giannakoulis #  1 , Eleni Xourgia  1 , Christina Routsi  1 , Anastasia Kotanidou  1 , Ilias I Siempos  2   3
Affiliations
Meta-Analysis

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

Eleni Papoutsi et al. Crit Care. .

Abstract

Background: Although several international guidelines recommend early over late intubation of patients with severe coronavirus disease 2019 (COVID-19), this issue is still controversial. We aimed to investigate the effect (if any) of timing of intubation on clinical outcomes of critically ill patients with COVID-19 by carrying out a systematic review and meta-analysis.

Methods: PubMed and Scopus were systematically searched, while references and preprint servers were explored, for relevant articles up to December 26, 2020, to identify studies which reported on mortality and/or morbidity of patients with COVID-19 undergoing early versus late intubation. "Early" was defined as intubation within 24 h from intensive care unit (ICU) admission, while "late" as intubation at any time after 24 h of ICU admission. All-cause mortality and duration of mechanical ventilation (MV) were the primary outcomes of the meta-analysis. Pooled risk ratio (RR), pooled mean difference (MD) and 95% confidence intervals (CI) were calculated using a random effects model. The meta-analysis was registered with PROSPERO (CRD42020222147).

Results: A total of 12 studies, involving 8944 critically ill patients with COVID-19, were included. There was no statistically detectable difference on all-cause mortality between patients undergoing early versus late intubation (3981 deaths; 45.4% versus 39.1%; RR 1.07, 95% CI 0.99-1.15, p = 0.08). This was also the case for duration of MV (1892 patients; MD - 0.58 days, 95% CI - 3.06 to 1.89 days, p = 0.65). In a sensitivity analysis using an alternate definition of early/late intubation, intubation without versus with a prior trial of high-flow nasal cannula or noninvasive mechanical ventilation was still not associated with a statistically detectable difference on all-cause mortality (1128 deaths; 48.9% versus 42.5%; RR 1.11, 95% CI 0.99-1.25, p = 0.08).

Conclusions: The synthesized evidence suggests that timing of intubation may have no effect on mortality and morbidity of critically ill patients with COVID-19. These results might justify a wait-and-see approach, which may lead to fewer intubations. Relevant guidelines may therefore need to be updated.

Keywords: Acute respiratory distress syndrome; Acute respiratory failure; Coronavirus; Delayed; Intensive care unit; Pneumonia.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Study flow diagram
Fig. 2
Fig. 2
All-cause mortality of patients with COVID-19 undergoing early versus late intubation. Pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using a random effects model
Fig. 3
Fig. 3
Duration of mechanical ventilation of patients with COVID-19 undergoing early versus late intubation. Mean difference (MD) and 95% confidence intervals (CI) were calculated using a random effects model
Fig. 4
Fig. 4
All-cause mortality of patients with COVID-19 undergoing intubation without versus with a prior trial of high flow nasal cannula (HFNC) or noninvasive mechanical ventilation (NIV). Pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using a random effects model. The authors of two [13, 19] of the studies included in this analysis considered a trial of NIV lasting less than 24 h as inconsequential
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