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Observational Study
. 2024 Jun 1;52(6):930-941.
doi: 10.1097/CCM.0000000000006229. Epub 2024 Feb 23.

Intubation Decision Based on Illness Severity and Mortality in COVID-19: An International Study

Athanasios Chalkias  1   2 , Yiyuan Huang  3 , Anis Ismail  4 , Ioannis Pantazopoulos  5 , Nikolaos Papagiannakis  5 , Brayden Bitterman  4 , Elizabeth Anderson  4 , Tonimarie Catalan  4 , Grace K Erne  4 , Caroline R Tilley  4 , Abiola Alaka  4 , Kingsley M Amadi  4 , Feriel Presswalla  4 , Pennelope Blakely  4 , Enrique Bernal-Morell  6 , Iria Cebreiros López  7 , Jesper Eugen-Olsen  8 , Luis García de Guadiana Romualdo  9 , Evangelos J Giamarellos-Bourboulis  10 , Sven H Loosen  11 , Jochen Reiser  12 , Frank Tacke  13 , Anargyros Skoulakis  5 , Eleni Laou  5 , Mousumi Banerjee  3 , Rodica Pop-Busui  14 , Salim S Hayek  4 ; International Study of Inflammation in COVID-19 (ISIC) Investigator Group
Collaborators, Affiliations
Observational Study

Intubation Decision Based on Illness Severity and Mortality in COVID-19: An International Study

Athanasios Chalkias et al. Crit Care Med. .

Abstract

Objectives: To evaluate the impact of intubation timing, guided by severity criteria, on mortality in critically ill COVID-19 patients, amidst existing uncertainties regarding optimal intubation practices.

Design: Prospective, multicenter, observational study conducted from February 1, 2020, to November 1, 2022.

Setting: Ten academic institutions in the United States and Europe.

Patients: Adults (≥ 18 yr old) confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hospitalized specifically for COVID-19, requiring intubation postadmission. Exclusion criteria included patients hospitalized for non-COVID-19 reasons despite a positive SARS-CoV-2 test.

Interventions: Early invasive mechanical ventilation (EIMV) was defined as intubation in patients with less severe organ dysfunction (Sequential Organ Failure Assessment [SOFA] < 7 or Pa o2 /F io2 ratio > 250), whereas late invasive mechanical ventilation (LIMV) was defined as intubation in patients with SOFA greater than or equal to 7 and Pa o2 /F io2 ratio less than or equal to 250.

Measurements and main results: The primary outcome was mortality within 30 days of hospital admission. Among 4464 patients, 854 (19.1%) required mechanical ventilation (mean age 60 yr, 61.7% male, 19.3% Black). Of those, 621 (72.7%) were categorized in the EIMV group and 233 (27.3%) in the LIMV group. Death within 30 days after admission occurred in 278 patients (42.2%) in the EIMV and 88 patients (46.6%) in the LIMV group ( p = 0.28). An inverse probability-of-treatment weighting analysis revealed a statistically significant association with mortality, with patients in the EIMV group being 32% less likely to die either within 30 days of admission (adjusted hazard ratio [HR] 0.68; 95% CI, 0.52-0.90; p = 0.008) or within 30 days after intubation irrespective of its timing from admission (adjusted HR 0.70; 95% CI, 0.51-0.90; p = 0.006).

Conclusions: In severe COVID-19 cases, an early intubation strategy, guided by specific severity criteria, is associated with a reduced risk of death. These findings underscore the importance of timely intervention based on objective severity assessments.

Trial registration: ClinicalTrials.gov NCT04818866.

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Conflict of interest statement

Dr. Hayek is funded by the National Heart, Lung, and Blood Institute 1R01HL153384-01, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) 1R01DK12801201A1, U01-DK119083-03S1, and the Frankel Cardiovascular Center COVID-19: Impact Research Ignitor (U-M G024231) award. Dr. Pop-Busui is supported by the National Institutes of Health (NIH)/NIDDK-1-R01-DK-107956-01, NIH U01 DK119083, the Juvenile Diabetes Research Foundation 5-COE-2019-861-S-B, and by a Pilot and Feasibility Grant from the Michigan Diabetes Research Center (NIH Grant P30-DK020572). Dr. Huang disclosed work for hire. Dr. Giamarellos-Bourboulis’ institution received funding from Abbott Products Operations AG, BioMerieux, and MSD; they received funding from Abbott CH, BioMérieux, Brahms GmbH, GSK, InflaRx GmbH, Sobi, XBiotech, AbbVie, Johnson & Johnson, MSD, Novartis, UCB, and from the Horizon2020 Marie-Curie Project European Sepsis Academy, the Horizon 2020 European Grants ImmunoSep and RISKinCOVID, and from the Horizon Europe project EPIC-CROWN-2. Drs. Reiser and Banerjee received support for article research from the NIH. Dr. Reiser disclosed they are a co-founder and co-chair of the Scientific Advisory Board of Walden Biosciences; they received support for article research from Rush University Medical Center. Dr. Banerjee’s institution received funding from the NIDDK; they received funding from Novo Nordisk, Roche, and Lexicon Pharmaceuticals. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Comment in

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