Clinical Significance of Timing of Intubation in Critically Ill Patients with COVID-19: A Multi-Center Retrospective Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design and Participants
2.2. Data Collection and Definitions
2.3. Classification by Intubation Timing and Status
2.4. Outcomes
2.5. Statistical Analysis
3. Results
3.1. Patient Characteristics
3.2. Laboratory Indices, Severity of Illness, and Clinical Course
3.3. Clinical Outcomes
3.4. Effects of Early Intubation on Mortality
4. Discussion
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Variables | Early Intubation (n = 23) | Initially Nonintubated (n = 24) | p Value a | Late Intubation (n = 16) | p Value b |
---|---|---|---|---|---|
Age | 72 (64–76) | 69 (60–78) | 0.655 | 66 (59–77) | 0.475 |
Male | 14 (60.9) | 14 (58.3) | 0.859 | 10 (62.5) | 0.918 |
Body mass index, kg/m2 | 22.8 (21.0–26.7) | 25.6 (22.5–27.1) | 0.167 | 25.1 (22.7–27.3) | 0.241 |
Comorbidities | |||||
Any comorbidities | 16 (69.6) | 19 (79.2) | 0.450 | 13 (81.2) | 0.480 |
Hypertension | 10 (43.5) | 11 (45.8) | 0.871 | 8 (50) | 0.688 |
Diabetes | 10 (43.5) | 8 (33.3) | 0.474 | 7 (43.8) | 0.987 |
Chronic kidney disease | 1 (4.3) | 2 (8.3) | >0.999 | 2 (12.5) | 0.557 |
Dementia | 2 (8.7) | 3 (12.5) | >0.999 | 1 (6.2) | >0.999 |
Cerebrovascular disease | 0 (0) | 2 (8.3) | 0.489 | 1 (6.2) | 0.410 |
Malignancy | 2 (8.7) | 4 (16.7) | 0.666 | 4 (25) | 0.205 |
Cardiovascular disease | 4 (17.4) | 4 (16.7) | >0.999 | 2 (12.5) | >0.999 |
Chronic lung disease | 3 (13.0) | 1 (4.2) | 0.348 | 1 (6.2) | 0.631 |
Chronic liver disease | 1 (4.3) | 2 (8.3) | >0.999 | 0 (0) | >0.999 |
Duration of symptoms before admission, days | 7 (5–11) | 5 (4–12) | 0.280 | 5 (3–10) | 0.143 |
Presenting symptoms | |||||
Fever | 18 (78.3) | 16 (66.7) | 0.374 | 9 (56.2) | 0.174 |
Dyspnea | 19 (82.6) | 17 (70.8) | 0.341 | 12 (75) | 0.694 |
Cough | 12 (52.2) | 14 (58.3) | 0.671 | 8 (50) | 0.894 |
Sputum | 10 (43.5) | 10 (41.7) | 0.900 | 6 (37.5) | 0.709 |
Myalgia | 5 (21.7) | 5 (20.8) | >0.999 | 4 (25) | >0.999 |
Fatigue | 3 (13.0) | 7 (29.2) | 0.286 | 6 (37.5) | 0.123 |
Diarrhea | 2 (8.7) | 5 (20.8) | 0.416 | 2 (12.5) | >0.999 |
Vital signs at the time of ICU admission | |||||
Mean arterial pressure, mmHg | 93 (90–107) | 93 (86–102) | 0.539 | 93 (86–97) | 0.388 |
Heart rate, beats/min | 85 (76–124) | 88 (80–100) | 0.915 | 92 (74–100) | 0.808 |
Respiratory rate, breaths/min | 28 (22–34) | 21 (20–26) | 0.007 | 21 (20–29) | 0.057 |
Body temperature, ℃ | 37.3 (36.4–37.8) | 36.8 (36.5–37.4) | 0.781 | 36.9 (36.6–37.4) | 0.863 |
Variables | Early Intubation (n = 23) | Initially Nonintubated (n = 24) | p Value a | Late Intubation (n = 16) | p Value b |
---|---|---|---|---|---|
White blood cells, 103/L | 6.89 (4.73–9.82) | 7.16 (5.21–9.55) | 0.907 | 7.16 (5.9–9.96) | 0.679 |
Hemoglobin, g/dL | 13.0 (11.2–14.4) | 13.2 (11.5–14.4) | 0.935 | 13.1 (10.9–14.1) | 0.828 |
Hematocrit, % | 37.6 (33.1–42) | 39.3 (33.2–41.2) | 0.849 | 38.7 (31.8–40.6) | 0.706 |
Platelets, 103/L | 197 (146–296) | 211 (156–295) | 0.702 | 220 (156–295) | 0.396 |
C–reactive protein, mg/dL | 9.98 (5.66–15.59) | 10.27 (6.46–13.83) | 0.983 | 11 (7.39–17.43) | 0.668 |
Procalcitonin, mmol/L | 0.27 (0.12–0.74) | 0.11 (0.1–0.21) | 0.044 | 0.13 (0.1–0.21) | 0.082 |
Lactate, mmol/L | 1.8 (1.3–2.5) | 1.6 (1.3–2.3) | 0.557 | 1.8 (1.3–2.4) | 0.947 |
Albumin, g/dL | 3.3 (3–3.5) | 3.4 (3.3–3.5) | 0.298 | 3.4 (3.3–3.7) | 0.329 |
AST, U/L | 48 (35–81) | 50 (35–91) | 0.717 | 50 (33–65) | 0.875 |
ALT, U/L | 27 (19–34) | 20 (13–57) | 0.302 | 22 (13–53) | 0.346 |
Total bilirubin, mg/dL | 0.62 (0.4–0.85) | 0.54 (0.32–0.83) | 0.537 | 0.6 (0.3–0.83) | 0.607 |
BUN, mg/dL | 15.7 (12.5–24.7) | 15.6 (8.9–22.6) | 0.609 | 16.8 (11.8–35.3) | 0.842 |
Creatinine, mg/dL | 0.9 (0.7–1.2) | 0.9 (0.67–1.45) | 0.741 | 0.95 (0.7–1.9) | 0.484 |
Sodium, mmol/L | 134 (132–139) | 137 (133–138) | 0.407 | 137 (132–139) | 0.330 |
Potassium, mmol/L | 3.9 (3.3–4.3) | 4 (3.3–4.7) | 0.327 | 3.9 (3.3–4.6) | 0.427 |
Glucose, mg/dL | 156 (117–197) | 139 (111–168) | 0.312 | 161 (122–172) | 0.966 |
LDH, U/L | 486 (410–559) | 442 (370–632) | 0.606 | 468 (344–698) | 0.818 |
D-dimer, ug/mL | 2.0 (0.77–3.87) | 2.5 (1.23–6.4) | 0.447 | 2.03 (1.07–3.74) | 0.642 |
Prothrombin time, INR | 1.13 (1.02–1.27) | 1.08 (1.02–1.26) | 0.910 | 1.08 (1.02–1.27) | 0.908 |
NT–proBNP, pg/mL | 826 (243–1376) | 570 (316–1395) | 0.648 | 540 (372–2026) | 0.917 |
Troponin I, ng/mL | 0.03 (0.02–0.18) | 0.02 (0.01–0.02) | 0.073 | 0.02 (0.01–0.02) | 0.114 |
CK–MB, U/L | 1.5 (1–4.3) | 1.1 (0.8–1.8) | 0.025 | 1 (0.8–1.4) | 0.019 |
Variables | Early Intubation (n = 23) | Initially Nonintubated (n = 24) | p Value a | Late Intubation (n = 16) | p Value b |
---|---|---|---|---|---|
Severity of illness on ICU admission | |||||
Septic shock | 4 (17.4) | 2 (8.3) | 0.416 | 1 (6.2) | 0.631 |
Acute kidney injury | 7 (30.4) | 5 (20.8) | 0.450 | 4 (25) | >0.999 |
Acute cardiac injury | 8 (34.8) | 3 (12.5) | 0.071 | 2 (12.5) | 0.152 |
SOFA score | 3 (2–7) | 2 (2–4) | 0.134 | 3 (2–4) | 0.336 |
APACHE II score | 15 (10–17) | 11 (8–14) | 0.042 | 14 (8–15) | 0.252 |
ABGA at the time of diagnosis of ARDS | |||||
pH | 7.34 (7.31–7.44) | 7.45 (7.42–7.5) | 0.001 | 7.43 (7.4–7.49) | 0.013 |
PaCO2, mmHg | 37.6 (33.3–50.2) | 32.2 (26.8–36.5) | 0.001 | 32.3 (23.8–37.1) | 0.002 |
PaO2, mmHg | 77.3 (55.3–85) | 67.8 (55–82.3) | 0.389 | 67.8 (55.7–79.7) | 0.339 |
HCO3, mmol/L | 22.6 (21.1–25.4) | 22.4 (18.8–25.5) | 0.672 | 20.8 (17.4–26.3) | 0.259 |
PF ratio | 86 (69–123) | 144 (70–206) | 0.028 | 120 (62–188) | 0.204 |
ICU management | |||||
HFNC | 13 (56.5) | 24 (100) | <0.001 | 16 (100) | 0.002 |
NM blockade | 15 (65.2) | 9 (37.5) | 0.057 | 9 (56.2) | 0.571 |
CRRT | 5 (21.7) | 5 (20.8) | >0.999 | 5 (31.2) | 0.711 |
Tracheostomy | 9 (39.1) | 7 (29.2) | 0.471 | 7 (43.8) | 0.773 |
ECMO | 3 (13.0) | 4 (16.7) | >0.999 | 4 (25) | 0.415 |
Medical treatment | |||||
Antiviral agents | |||||
Lopinavir-ritonavir | 20 (87.0) | 16 (66.7) | 0.101 | 11 (68.8) | 0.235 |
Darunavir–cobicistat | 3 (13.0) | 7 (29.2) | 0.286 | 5 (31.2) | 0.235 |
Antibiotics | 23 (100) | 24 (100) | 16 (100) | ||
Hydroxychloroquine | 20 (87.0) | 22 (91.7) | 0.666 | 14 (87.5) | >0.999 |
Glucocorticoid | 18 (78.3) | 19 (79.2) | >0.999 | 15 (93.8) | 0.370 |
Medical event during ICU care | |||||
Septic shock | 20 (87.0) | 15 (62.5) | 0.055 | 14 (87.5) | >0.999 |
Acute kidney injury | 10 (43.5) | 7 (29.2) | 0.307 | 7 (43.8) | 0.987 |
Acute cardiac injury | 10 (43.5) | 5 (20.8) | 0.096 | 4 (25) | 0.237 |
VAP or HAP | 7 (30.4) | 1 (4.2) | 0.023 | 1 (6.2) | 0.109 |
CRBSI | 4 (17.4) | 3 (12.5) | 0.701 | 3 (18.8) | >0.999 |
Bleeding | 3 (13.0) | 3 (12.5) | >0.999 | 3 (18.8) | 0.674 |
CPCR | 1 (4.3) | 3 (12.5) | 0.609 | 2 (12.5) | 0.557 |
Variables | Early Intubation (n = 23) | Initially Nonintubated (n = 24) | p Value a | Late Intubation (n = 16) | p Value b |
---|---|---|---|---|---|
In-hospital mortality | 13 (56.5) | 8 (33.3) | 0.110 | 7 (43.8) | 0.433 |
Main cause of death | |||||
COVID-19 related ARDS | 7/13 (53.8) | 4/8 (50) | >0.999 | 4/7 (57.1) | >0.999 |
VAP | 3/13 (23.1) | 1/8 (12.5) | >0.999 | 1/7 (14.3) | >0.999 |
CRBSI | 2/13 (15.4) | 0/8 (0) | 0.505 | 0/7 (0) | 0.521 |
Acute kidney injury | 0/13 (0) | 1/8 (12.5) | 0.381 | 1/7 (14.3) | 0.350 |
Myocardial infarction | 1/13 (7.7) | 1/8 (12.5) | 0.999 | 1/7 (14.3) | >0.999 |
Unknown c | 0/13 (0) | 1/8 (12.5) | 0.381 | 0/12 (0) | |
Ventilator-free days | 9 (0–18) | 28 (9–45) | 0.008 | 25 (7–45) | 0.033 |
ICU days d | 13 (7–33) | 14 (7–48) | 0.691 | 47 (13–74) | 0.101 |
Days of MV d | 10 (4–24) | 6 (0–25) | 0.325 | 20 (9–57) | 0.177 |
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Lee, Y.H.; Choi, K.-J.; Choi, S.H.; Lee, S.Y.; Kim, K.C.; Kim, E.J.; Lee, J. Clinical Significance of Timing of Intubation in Critically Ill Patients with COVID-19: A Multi-Center Retrospective Study. J. Clin. Med. 2020, 9, 2847. https://doi.org/10.3390/jcm9092847
Lee YH, Choi K-J, Choi SH, Lee SY, Kim KC, Kim EJ, Lee J. Clinical Significance of Timing of Intubation in Critically Ill Patients with COVID-19: A Multi-Center Retrospective Study. Journal of Clinical Medicine. 2020; 9(9):2847. https://doi.org/10.3390/jcm9092847
Chicago/Turabian StyleLee, Yong Hoon, Keum-Ju Choi, Sun Ha Choi, Shin Yup Lee, Kyung Chan Kim, Eun Jin Kim, and Jaehee Lee. 2020. "Clinical Significance of Timing of Intubation in Critically Ill Patients with COVID-19: A Multi-Center Retrospective Study" Journal of Clinical Medicine 9, no. 9: 2847. https://doi.org/10.3390/jcm9092847