Risk Factors and Outcomes Associated With Re-Intubation Secondary to Respiratory Failure in Patients With COVID-19 ARDS

Abstract

Background: COVID-19 is associated with variable symptoms and clinical sequelae. Studies have examined the clinical course of these patients, finding a prolonged need for invasive ventilation and variable re-intubation rates. However, no research has investigated factors and outcomes related to re-intubation secondary to respiratory failure among patients with COVID-19 with ARDS.

Methods: We conducted a single-center, retrospective study on subjects intubated for ARDS secondary to COVID-19. The primary outcome was re-intubation status; secondary outcomes were hospital and ICU stay and mortality. Data were analyzed using between-group comparisons using chi-square testing for categorical information and Student t test for quantitative data. Univariate and multivariate logistic regression was performed to determine factors related to re-intubation and mortality as dependent variables.

Results: One hundred and fourteen subjects were included, of which 32% required re-intubation. No between-group differences were detected for most demographic variables or comorbidities. No differences were detected in COVID-19 treatments, noninvasive respiratory support, mechanical circulatory support, or duration of ventilation. Midazolam (odds ratio [OR] 5.55 [95% CI 1.83-16.80], P = .002), fentanyl (OR 3.64 [95% CI 1.26-10.52], P = .02), and APACHE II scores (OR 1.08 [95% CI 1.030-1.147], P = .005) were independently associated with re-intubation (area under the curve = 0.81). Re-intubated subjects had extended hospital (36.7 ± 22.7 d vs 26.1 ± 12.1 d, P = .01) and ICU (29.6 ± 22.4 d vs 15.8 ± 10.4 d, P < .001) stays. More subjects died who failed extubation (49% vs 3%, P < .001). Age (OR 1.07 [95% CI 1.02-1.23], P = .005), male sex (OR 4.9 [95% CI 1.08-22.35], P = .041), positive Confusion Assessment Method for the ICU (CAM-ICU) (OR 5.43 [95% CI 1.58-18.62], P = .007), and re-intubation (OR 12.75 [95% CI 2.80-57.10], P < .001) were independently associated with death (area under the curve = 0.93).

Conclusions: Midazolam, fentanyl, and higher APACHE II scores were independently associated with re-intubation secondary to respiratory failure in subjects with COVID-19-related ARDS. Furthermore, age, male sex, positive CAM-ICU, and re-intubation were independently associated with mortality. Re-intubation also correlated with prolonged hospital and ICU stay.

Keywords: ARDS; COVID-19; analgesic; delirium; extubation failure; mechanical ventilation; mortality; re-intubation; respiratory failure; sedation.

Fig. 1.

Receiver operating characteristic curves of the entire model, midazolam, fentanyl, and Acute Physiology and Chronic Health Evaluation (APACHE II) score obtained when predicting re-intubation. Area under the curve for the entire model was 0.807. Area under the curve was 0.685 for midazolam, 0.680 for fentanyl use, and 0.704 for APACHE II score. APACHE II = Acute Physiology and Chronic Health Evaluation II.

Fig. 2.

Receiver operating characteristic curves of the entire model, subject age, male sex, re-intubation within 7 d, and positive Confusion Assessment Method for the ICU (CAM-ICU) score obtained when predicting mortality. Area under the curve for the entire model was 0.933. Area under the curve was 0.686 for subject age, 0.684 for male sex, 0.811 for re-intubation within 7 d, and 0.651 for positive CAM-ICU score. CAM-ICU = Confusion Assessment Method for the ICU.