Impact of time to intubation on mortality and pulmonary sequelae in critically ill patients with COVID-19: a prospective cohort study

Question We evaluated whether the time between first respiratory support and intubation of patients receiving invasive mechanical ventilation (IMV) due to COVID-19 was associated with mortality or pulmonary sequelae. Materials and methods Prospective cohort of critical COVID-19 patients on IMV. Patients were classified as early intubation if they were intubated within the first 48 h from the first respiratory support or delayed intubation if they were intubated later. Surviving patients were evaluated after hospital discharge. Results We included 205 patients (140 with early IMV and 65 with delayed IMV). The median [p25;p75] age was 63 [56.0; 70.0] years, and 74.1% were male. The survival analysis showed a significant increase in the risk of mortality in the delayed group with an adjusted hazard ratio (HR) of 2.45 (95% CI 1.29–4.65). The continuous predictor time to IMV showed a nonlinear association with the risk of in-hospital mortality. A multivariate mortality model showed that delay of IMV was a factor associated with mortality (HR of 2.40; 95% CI 1.42–4.1). During follow-up, patients in the delayed group showed a worse DLCO (mean difference of − 10.77 (95% CI − 18.40 to − 3.15), with a greater number of affected lobes (+ 1.51 [95% CI 0.89–2.13]) and a greater TSS (+ 4.35 [95% CI 2.41–6.27]) in the chest CT scan. Conclusions Among critically ill patients with COVID-19 who required IMV, the delay in intubation from the first respiratory support was associated with an increase in hospital mortality and worse pulmonary sequelae during follow-up.

Early versus Delayed Intubation and Technique in COVID-19: A Review Article

Background: The novel coronavirus 2019 is the cause of the 2020 pandemic that was announced by the world health organization in March 2020. The coronavirus attacks the respiratory system and causes mild to severe hypoxemia. Therefore, a fraction of COVID-19 patients may need intubation and mechanical ventilation. Methods: We conducted a narrative review by searching for articles that mentioned the time of intubation for COVID-19 patients and intubation techniques in PubMed, Google Scholar, Scopus, the Web of scenic, the Cochrane library, and Embase, as well as manual searching. All the selected reviews and studies were limited to humans and the English language. Results: The first data from China shows that 5% of patients require intubation and mechanical ventilation (MV), and there has been considerable debate about the timing of intubation for patients with acute respiratory failure and the technique of intubation. At first, the specialists recommended early intubation. Although we are more familiar with the pathophysiology of coronavirus, the drawbacks and the benefits of early intubation are still controversial. In addition, the intubation process itself is an aerosol-generating procedure and carries a high risk for patients and health care providers. In this review, we aim to review the previous studies and guidelines recommendations related to the time of intubation and intubation technique for COVID-19 patients. Conclusion: Previous research has suggested that early tracheal intubation should be prioritized in severe COVID-19 patients, whereas other studies advocate late intubation due to poor intubation outcomes and weaning difficulties. However, intubation timing should be based on personalized medicine and case-by-case decision making to ensure the best care and benefit of patients. And relying only on theoretical justification may not have good consequences.

HI (HARLEQUIN ICHTHYOSIS) BABY

HI is a very rare type of genetical abnormality but can be seen and scared by seeing various social media footages. It is associated with deletion and truncation mutations of a keratinocyte lipid transporter. Harlequin disorder is categorized by diffuse epidermal hyperkeratinization along with defective desquamation. During birth, the HI phenotype is conspicuous with thick hyperkeratotic plate-like scales with deep dermal ssures, severe ectropion and eclabium, among other ndings. In this ichthyosis marked eclabium and ectropion are present secondary to the taut as well as in the unyielding skin. The ears may be inattentive, absent or poorly developed. Even the arms, feet, and digits have exion contractures and may be hypoplastic. The skin wall is harshly compromised, leading to undue water loss, causes electrolyte abnormalities, temperature alteration and an increased risk of deadly infection. Some of the primary treatments are smearing retinoids application for shedding the hard and scaly skin, topical antibiotics application can prevent infection, insertion an ET tube in the airway to assistance with breathing, applying lubricating eye drops or protective devices on the eyes. Following ongoing treatment like humidied incubator (for premature infants), continuous monitoring of TPR and SpO2, early intubation(optional), frequent cultures of the skin should be taken for lab testing, monitoring serum electrolyte levels, maintaining a germ-free environment to evade infection etc.

Integrated oxygen therapy consisting of non invasive ventilation and nasal cannulae in respiratory failure secondary to COVID-19 pneumonia: Case series

Patients with moderate to severe COVID-19 disease develop hypoxemic respiratory failure demonstrating profound degrees of hypoxia with little or no distress. This has put the conventional management consisting of an early intubation in question. In this case series, we attempted an integrated oxygen strategy utilizing non invasive ventilation with standard oxygen therapy (SO) via nasal cannula. We managed both the patients with successful outcomes, without the need of intubation. Hence, integrated oxygen therapy was successfully utilized for the ventilatory management of moderate to severe COVID-19 patients by improving oxygenation, making patients more comfortable and reducing the work of breathing. By complete avoidance of intubation, this technique might help in preservation of much-needed critical care ventilators and help improve patient outcomes in the areas hit hard by the pandemic.

Interhospital transfer of COVID-19 patients treated with high-flow nasal oxygen therapy

At the start of the COVID-19 pandemic, early intubation was recommended on the basis of worldwide observations of severe hypoxemia. However, some patients were ultimately able to benefit from high-flow nasal cannula (HFNC) and thus avoid intubation. During the “second wave” (September to December 2020 in France), some emergency departments implemented HFNC in patients with severe COVID-19. The question then arose regarding the transfer of these most serious patients to intensive care units (ICU) and of the respiratory modalities to be used during this transfer. To assess the feasibility of interhospital transfers of COVID-19 patients needing HFNC, we conducted a bi-centric prospective observational study of all medical transfers of patients needing HFNC with the Chambéry and Angers (France) mobile emergency and intensive care service (SMUR) during the “second wave” of the COVID-19 pandemic in France. Analysis of these 42 patients showed no significant variation in the respiratory requirements during the transfer. Overall, 52% of patients were intubated during their stay in ICU, including three patients intubated before or during transfer. Interhospital transfer with HFNC is very high-risk, and intubation remains indicated in the most unstable patients. However, 48% of patients benefited from HFNC and were thus able to avoid intubation during their transfer and ICU stay; for these patients, intubation would probably have been indicated in the absence of available HFNC techniques.

Timing to Intubation COVID-19 Patients: Can We Put It Off Until Tomorrow?

Background: The decision to intubate COVID-19 patients receiving non-invasive respiratory support is challenging, requiring a fine balance between early intubation and risks of invasive mechanical ventilation versus the adverse effects of delaying intubation. This present study analyzes the relationship between intubation day and mortality in COVID-19 patients. Methods: We performed a unicentric retrospective cohort study considering all adult laboratory-confirmed SARS-CoV-2 infection consecutively admitted at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil, between March 2020 and August 2020 requiring invasive mechanical ventilation. The primary outcome was all-cause mortality within 28 days after intubation, and a Cox model was used to evaluate the effect of time from onset of symptoms to intubation in mortalityResults: A total of 592 (20%) adult consecutive patients out of 3020 admitted with COVID-19 were intubated during the study period. The median time from admission to intubation was one day (interquartile range, 0-3), and 310 patients (52%) who were intubated and mechanically ventilated deceased 28 days after intubation. Each additional day between the onset of symptoms and intubation was significantly associated with higher in-hospital death (adjusted hazard ratio, 1.018; 95% CI, 1.005-1.03).Conclusion: Among patients infected with SARS-CoV-2 who were intubated and mechanically ventilated, delaying intubation in the course of symptoms may be associated with higher mortality.Trial registration: The study protocol was approved by the local Ethics Committee (opinion number 3.990.817; CAAE: 30417520.0.0000.0068.

Early intubation versus late intubation for COVID-19 patients: An in situ simulation identifying factors affecting performance and infection control in airway management

COVID-19 poses an infectious risk to healthcare workers especially during airway management. We compared the impact of early versus late intubation on infection control and performance in a randomised in situ simulation, using fluorescent powder as a surrogate for contamination. Twenty anaesthetists and intensivists intubated a simulated patient with COVID-19. The primary outcome was the degree of contamination. The secondary outcomes included the use of bag-valve-mask ventilation, the incidence of manikin cough, intubation time, first attempt success and heart rate variability as a measure of stress. The contamination score was significantly increased in the late intubation group, mean (standard deviation, SD) 17.20 (6.17), 95% confidence intervals (CI) 12.80 to 21.62 versus the early intubation group, mean (SD) 9.90 (5.13), 95% CI 6.23 to 13.57, P = 0.005. The contamination score was increased after simulated cough occurrence (mean (SD) 18.0 (5.09) versus 5.50 (2.10) in those without cough; P<0.001), and when first attempt laryngoscopy failed (mean (SD) of 17.1 (6.41) versus 11.6 (6.20) P = 0.038). The incidence of bag-mask ventilation was higher in the late intubation group (80% versus 30%; P=0.035). There was no significant difference in intubation time, incidence of failed first attempt laryngoscopy or heart rate variability between the two groups. Late intubation in patients with COVID-19 may be associated with greater laryngoscopist contamination and potential aerosol-generating events compared with early intubation. There was no difference in performance measured by intubation time and incidence of first attempt success. Late intubation, especially when resources are limited, may be a valid approach. However, strict infection control and appropriate personal protective equipment usage is recommended in such cases.

Reduced critical care demand with early CPAP and proning in COVID-19 at Bradford: A single-centre cohort

Background Guidance in COVID-19 respiratory failure has favoured early intubation, with concerns over the use of CPAP. We adopted early CPAP and self-proning, and evaluated the safety and efficacy of this approach. Methods This retrospective observational study included all patients with a positive COVID-19 PCR, and others with high clinical suspicion. Our protocol advised early CPAP and self-proning for severe cases, aiming to prevent rather than respond to deterioration. CPAP was provided outside critical care by ward staff supported by physiotherapists and an intensive critical care outreach program. Data were analysed descriptively and compared against a large UK cohort (ISARIC). Results 559 patients admitted before 1 May 2020 were included. 376 were discharged alive, and 183 died. 165 patients (29.5%) received CPAP, 40 (7.2%) were admitted to critical care and 28 (5.0%) were ventilated. Hospital mortality was 32.7%, and 50% for critical care. Following CPAP, 62% of patients with S:F or P:F ratios indicating moderate or severe ARDS, who were candidates for escalation, avoided intubation. Figures for critical care admission, intubation and hospital mortality are lower than ISARIC, whilst critical care mortality is similar. Following ISARIC proportions we would have admitted 92 patients to critical care and intubated 55. Using the described protocol, we intubated 28 patients from 40 admissions, and remained within our expanded critical care capacity. Conclusion Bradford’s protocol produced good results despite our population having high levels of co-morbidity and ethnicities associated with poor outcomes. In particular we avoided overloading critical care capacity. We advocate this approach as both effective and safe.