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Observational Study
. 2021 Dec;160(6):2112-2122.
doi: 10.1016/j.chest.2021.06.008. Epub 2021 Jun 15.

Practice, Outcomes, and Complications of Emergent Endotracheal Intubation by Critical Care Practitioners During the COVID-19 Pandemic

Peter C Nauka  1 , Jen-Ting Chen  2 , Ariel L Shiloh  2 , Lewis A Eisen  2 , Daniel G Fein  3
Affiliations
Observational Study

Practice, Outcomes, and Complications of Emergent Endotracheal Intubation by Critical Care Practitioners During the COVID-19 Pandemic

Peter C Nauka et al. Chest. 2021 Dec.

Abstract

Background: For patients with COVID-19 who undergo emergency endotracheal intubation, data are limited regarding the practice, outcomes, and complications of this procedure.

Research question: For patients with COVID-19 requiring emergency endotracheal intubation, how do the procedural techniques, the incidence of first-pass success, and the complications associated with the procedure compare with intubations of critically ill patients before the COVID-19 pandemic?

Study design and methods: We conducted a retrospective study of adult patients with COVID-19 at Montefiore Medical Center who underwent first-time endotracheal intubation by critical care physicians between July 19, 2019, and May 1, 2020. The first COVID-19 patient was admitted to our institution on March 11, 2020; patients admitted before this date are designated the prepandemic cohort. Descriptive statistics were used to compare groups. A Fisher exact test was used to compare categorical variables. For continuous variables, a two-tailed Student t test was used for parametric variables or a Wilcoxon rank-sum test was used for nonparametric variables.

Results: One thousand two hundred sixty intubations met inclusion criteria (782 prepandemic cohort, 478 pandemic cohort). Patients during the pandemic were more likely to be intubated for hypoxemic respiratory failure (72.6% vs 28.1%; P < .01). During the pandemic, operators were more likely to use video laryngoscopy (89.4% vs 53.3%; P < .01) and neuromuscular blocking agents (86.0% vs 46.2%; P < .01). First-pass success was higher during the pandemic period (94.6% vs 82.9%; P < .01). The rate of associated complications was higher during the pandemic (29.5% vs 15.2%; P < .01), a finding driven by a higher rate of hypoxemia during or immediately after the procedure (25.7% vs 8.2%; P < .01).

Interpretation: Video laryngoscopy and neuromuscular blockade were used increasingly during the COVID-19 pandemic. Despite a higher rate of first-pass success during the pandemic, the incidence of complications associated with the procedure was higher.

Keywords: airway management; intratracheal; intubation; mechanical ventilation.

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Figures

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Graphical abstract
Figure 1
Figure 1
Flow diagram showing patients included in the cohort. EEI = emergent endotracheal intubation; OR = operating room.
Figure 2
Figure 2
Bar graph showing the number of intubation attempts before the pandemic and during pandemic period.
Figure 3
Figure 3
Graph showing intubation volume and FPS rates over study period. Study enrollment began on July 19, 2019. Given the lack of complete data from July 2019, only data from August 1, 2019, onward is depicted. FPS = first-pass success.
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