Early intubation and decreased in-hospital mortality in patients with coronavirus disease 2019

Abstract

Background: Some academic organizations recommended that physicians intubate patients with COVID-19 with a relatively lower threshold of oxygen usage particularly in the early phase of pandemic. We aimed to elucidate whether early intubation is associated with decreased in-hospital mortality among patients with novel coronavirus disease 2019 (COVID-19) who required intubation.

Methods: A multicenter, retrospective, observational study was conducted at 66 hospitals in Japan where patients with moderate-to-severe COVID-19 were treated between January and September 2020. Patients who were diagnosed as COVID-19 with a positive reverse-transcription polymerase chain reaction test and intubated during admission were included. Early intubation was defined as intubation conducted in the setting of ≤ 6 L/min of oxygen usage. In-hospital mortality was compared between patients with early and non-early intubation. Inverse probability weighting analyses with propensity scores were performed to adjust patient demographics, comorbidities, hemodynamic status on admission and time at intubation, medications before intubation, severity of COVID-19, and institution characteristics. Subgroup analyses were conducted on the basis of age, severity of hypoxemia at intubation, and days from admission to intubation.

Results: Among 412 patients eligible for the study, 110 underwent early intubation. In-hospital mortality was lower in patients with early intubation than those with non-early intubation (18 [16.4%] vs. 88 [29.1%]; odds ratio, 0.48 [95% confidence interval 0.27-0.84]; p = 0.009, and adjusted odds ratio, 0.28 [95% confidence interval 0.19-0.42]; p < 0.001). The beneficial effects of early intubation were observed regardless of age and severity of hypoxemia at time of intubation; however, early intubation was associated with lower in-hospital mortality only among patients who were intubated later than 2 days after admission.

Conclusions: Early intubation in the setting of ≤ 6 L/min of oxygen usage was associated with decreased in-hospital mortality among patients with COVID-19 who required intubation. Trial Registration None.

Keywords: Coronavirus infection; Critical care; Oxygen; Pulmonary function; Respiratory failure; Timing of intubation.

Fig. 1

Patient flow diagram. Among 4700 patients with coronavirus disease (COVID-19) in the J-RECOVER database, 412 adult patients were intubated after hospital admission and were therefore eligible for this study. A total of 110 (26.7%) patients underwent early intubation for whom ≤ 6 L/min of oxygen was administered immediately before intubation. Eighteen patients in the early intubation group and 39 patients in the non-early intubation group were excluded from inverse probability weighting (IPW) analyses due to missing covariates for propensity score calculation; hence, IPW analyses were performed for 355 patients