Endotracheal Intubation Strategy, Success, and Adverse Events Among Emergency Department Patients During the COVID-19 Pandemic

Abstract

Study objective: To describe endotracheal intubation practices in emergency departments by staff intubating patients early in the coronavirus disease 2019 (COVID-19) pandemic.

Methods: Multicenter prospective cohort study of endotracheal intubations conducted at 20 US academic emergency departments from May to December 2020, stratified by known or suspected COVID-19 status. We used multivariable regression to measure the association between intubation strategy, COVID-19 known or suspected status, first-pass success, and adverse events.

Results: There were 3,435 unique emergency department endotracheal intubations by 586 participating physicians or advanced practice providers; 565 (18%) patients were known or suspected of having COVID-19 at the time of endotracheal intubation. Compared with patients not known or suspected of COVID-19, endotracheal intubations of patients with known or suspected COVID-19 were more often performed using video laryngoscopy (88% versus 82%, difference 6.3%; 95% confidence interval [CI], 3.0% to 9.6%) and passive nasal oxygenation (44% versus 39%, difference 5.1%; 95% CI, 0.9% to 9.3%). First-pass success was not different between those who were and were not known or suspected of COVID-19 (87% versus 86%, difference 0.6%; 95% CI, -2.4% to 3.6%). Adjusting for patient characteristics and procedure factors in those with low anticipated airway difficulty (n=2,374), adverse events (most commonly hypoxia) occurred more frequently in patients with known or suspected COVID-19 (35% versus 19%, adjusted odds ratio 2.4; 95% CI, 1.7 to 3.3).

Conclusion: Compared with patients not known or suspected of COVID-19, endotracheal intubation of those confirmed or suspected to have COVID-19 was associated with a similar first-pass intubation success rate but higher risk-adjusted adverse events.

Figure 1

Flow chart of intubations performed by participants at 20 COVERED (COVID-19 Evaluation of Risks in EDs) US academic medical center EDs, May to December 2020. HCP, health care personnel.

Figure 2

Adjusted odds of first-pass success and adverse events related to COVID-19 known or suspected status in emergency department intubations during the COVID-19 pandemic at 20 COVERED (COVID-19 Evaluation of Risks in Emergency Departments) academic medical center emergency departments, May to December 2020. Because an interaction term between expected airway difficulty and known or suspected COVID-19 status was present, models are presented for the entire data set and analysis stratified by predicted airway difficulty. White dots indicate unadjusted estimates, green dots represent estimates adjusted for patient-level factors (acuity, reason for intubation), and black dots represent estimates adjusted for both patient-level and procedure-level factors (acuity, reason for intubation, passive nasal oxygenation, video laryngoscopy). Error bars represent 95% CIs. The forest plot on the left of the figure represents the outcome of first-pass success, and the forest plot on the right side of the figure represents adverse events. Adverse events included hypoxia, hypotension, esophageal intubation, dental injury, cardiac arrest, and failed airway.