Staving off intubation: Characteristics of outcomes in early versus delayed intubation in COVID-19

ABSTRACT

INTRODUCTION: Early in the COVID-19 pandemic, hypoxic patients were immediately intubated for fear of decompensation and aerosolizing the virus with non-invasive ventilation (NIV). Reports revealed a high mortality for intubated patients, prompting NIV such as high flow nasal cannula (HFNC) or noninvasive positive pressure ventilation (NIPPV). The literature lacks description of the outcomes between patients who were intubated immediately versus only after failing NIV. We describe the characteristics of patients who were intubated ?early,? defined as being intubated without NIV attempts, versus ?delayed?, defined as intubated after failed initial NIV use. METHODS: A prospective registry was created of all COVID-19 patients admitted to our urban academic medical center from March 2020 to July 2020. We analyzed this database to investigate escalation of respiratory support. Variables of interest included intubation, use of HFNC, NIPPV, and mortality. Logistic regression explored associations with mortality. RESULTS: A total of 109 patients were initiated on NIV. 102 began on HFNC and 7 on NIPPV. A total of 47 patients were intubated early. Of those started on HFNC, 24 (23.5%) were escalated directly to intubation. 23 (22.5%) received NIPPV, of which 16 (69.6%) required intubation. Of those started on NIPPV initially, 5 required intubation and 2 were downgraded to HFNC. Comparing early versus delayed intubation, the odds ratio for surviving intubation, adjusted for age and BMI, with a trial of NIV prior to intubation was 0.057 (0.002 - 0.562). For NIPPV, 94.4% (17 of 18) of patients intubated ?delayed? died, while 69.2% (27 of 39) patients intubated ?early? died. Unadjusted odds ratio for surviving intubation when having HFNC prior to intubation was 0.289 (0.081- 0.923), but lost statistical significance when adjusted for age and BMI. 64 patients (58.7%) who were started on NIV were never intubated during admission. CONCLUSIONS: This study suggests that NIV may be useful in the treatment of hypoxemia secondary to COVID-19 to prevent intubation, however the likelihood of survival decreases in those who fail NIV. Delayed intubations are associated with mortality when adjusted for age and BMI. Further research is needed to investigate who may benefit most from NIV as a supportive measure to prevent intubation.