To tube or not to tube? The COVID-19 enigma: A single centre experience of early vs late intubation
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Authors
Griffiths , H.
Bielskute, E.
Dyer , K.
Liu, Y.M.
Warnapura , L.
Issue Date
2022
Type
Published Abstract
Language
Keywords
Research Subject Categories::MEDICINE::Surgery::Anaesthetics and intensive care::Intensive care
Alternative Title
Abstract
To tube or not to tube? The COVID-19 enigma. A single centre experience of early vs late intubation
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COVID-19
Huw Griffiths, Egidija Bielskute, Kristyn Dyer, York-Mui Liu and Loku Warnapura
Luton & Dunstable University Hospital - Bedfordshire Hospitals NHS Foundation Trust.
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Abstract
Introduction: COVID-19, a disease typified by primary respiratory failure, lacks level one evidence on the most appropriate ventilation strategy when patients require critical care.1
The first wave in the United Kingdom (March - May 2020) was associated with early intubation due to lack of resources, infection control issues and poor evidence for non-invasive ventilation (NIV).
With the availability of more knowledge, NIV was utilised in the second wave (December 2020 - February 2021). This strategy however, delayed intubation for the subgroup of patients who failed the NIV trial.
At our institution, the first wave was characterised by early intubation, and the second wave by late intubation.
Objectives: The primary aim was to compare the mortality statistics of the two waves in our institution.
The secondary aim was to identify variables that could be relative contraindications to intubation, thus contributing to the design of an intubation pathway.
Methods: Retrospective observational study.
Inclusion criteria - COVID-19 patients requiring critical care (HDU or ICU) during the first and second wave.
Variables included: date of admission (DOA), age, gender, date of intubation, comorbidity burden and survival status (obtained from the trust digital records).
These variables were compared between the two groups using an excel spreadsheet.
Results: *The high mortality rate is a reflection of the patient group who presented in extremis having failed an NIV trial and had worsening disease progression. Often failure to deteriorate rapidly whilst on NIV inadvertently ‘delayed’ intubation.
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The gender distribution between the two groups was identical with 1/3 female and 2/3 male. The comorbidity burden was also very similar.
The strongest risk factor for mortality in the intubated cohort was age, with those aged over 65 having the worst outcome - Mortality Rate 93% (28/30).
Conclusion: At our institution there was no mortality difference between the two waves.
The second wave was characterised by predominant NIV usage, resulting in a smaller percentage of people requiring intubation. This had major logistical and cost saving benefits as less patients required level 3 care.
The early vs late intubation strategy seems to have no bearing on overall mortality, suggesting disease progression plays a more important role in outcome than ventilation modality.
COVID-19 is likely to be endemic in the population,2 thus devising a critical care pathway is essential to ensure standardisation of care and optimising patient outcomes.
The two waves have been characterised by extremes in approach. Our new pathway aims to take the middle ground of intubating at around day 5. This will allow the benefits of the NIV trial but also detect those deteriorating earlier. Relative contraindication to intubation will be age >65 years.
In summary, this study highlights the benefits of adopting a primary NIV strategy with the caveat that there is a small group of patients who deteriorate irrespective of treatments offered. To ensure the best opportunity for those with severe disease progression, a middle ground of intubating at around day 5 seems the most strategic future approach.