early intubation and decreased in hospital mortality in patients with coronavirus CORD-Papers-2022-06-02 (Version 1)

Title: Early intubation and decreased in-hospital mortality in patients with coronavirus disease 2019
Abstract: BACKGROUND: Some academic organizations recommended that physicians intubate patients with COVID-19 with a relatively lower threshold of oxygen usage particularly in the early phase of pandemic. We aimed to elucidate whether early intubation is associated with decreased in-hospital mortality among patients with novel coronavirus disease 2019 (COVID-19) who required intubation. METHODS: A multicenter retrospective observational study was conducted at 66 hospitals in Japan where patients with moderate-to-severe COVID-19 were treated between January and September 2020. Patients who were diagnosed as COVID-19 with a positive reverse-transcription polymerase chain reaction test and intubated during admission were included. Early intubation was defined as intubation conducted in the setting of 6 L/min of oxygen usage. In-hospital mortality was compared between patients with early and non-early intubation. Inverse probability weighting analyses with propensity scores were performed to adjust patient demographics comorbidities hemodynamic status on admission and time at intubation medications before intubation severity of COVID-19 and institution characteristics. Subgroup analyses were conducted on the basis of age severity of hypoxemia at intubation and days from admission to intubation. RESULTS: Among 412 patients eligible for the study 110 underwent early intubation. In-hospital mortality was lower in patients with early intubation than those with non-early intubation (18 [16.4%] vs. 88 [29.1%]; odds ratio 0.48 [95% confidence interval 0.270.84]; p = 0.009 and adjusted odds ratio 0.28 [95% confidence interval 0.190.42]; p < 0.001). The beneficial effects of early intubation were observed regardless of age and severity of hypoxemia at time of intubation; however early intubation was associated with lower in-hospital mortality only among patients who were intubated later than 2 days after admission. CONCLUSIONS: Early intubation in the setting of 6 L/min of oxygen usage was associated with decreased in-hospital mortality among patients with COVID-19 who required intubation. Trial Registration None. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13054-022-03995-1.
Published: 2022-05-06
Journal: Crit Care
DOI: 10.1186/s13054-022-03995-1
DOI_URL: http://doi.org/10.1186/s13054-022-03995-1
Author Name: Yamamoto Ryo
Author link: https://covid19-data.nist.gov/pid/rest/local/author/yamamoto_ryo
Author Name: Kaito Daiki
Author link: https://covid19-data.nist.gov/pid/rest/local/author/kaito_daiki
Author Name: Homma Koichiro
Author link: https://covid19-data.nist.gov/pid/rest/local/author/homma_koichiro
Author Name: Endo Akira
Author link: https://covid19-data.nist.gov/pid/rest/local/author/endo_akira
Author Name: Tagami Takashi
Author link: https://covid19-data.nist.gov/pid/rest/local/author/tagami_takashi
Author Name: Suzuki Morio
Author link: https://covid19-data.nist.gov/pid/rest/local/author/suzuki_morio
Author Name: Umetani Naoyuki
Author link: https://covid19-data.nist.gov/pid/rest/local/author/umetani_naoyuki
Author Name: Yagi Masayuki
Author link: https://covid19-data.nist.gov/pid/rest/local/author/yagi_masayuki
Author Name: Nashiki Eisaku
Author link: https://covid19-data.nist.gov/pid/rest/local/author/nashiki_eisaku
Author Name: Suhara Tomohiro
Author link: https://covid19-data.nist.gov/pid/rest/local/author/suhara_tomohiro
Author Name: Nagata Hiromasa
Author link: https://covid19-data.nist.gov/pid/rest/local/author/nagata_hiromasa
Author Name: Kabata Hiroki
Author link: https://covid19-data.nist.gov/pid/rest/local/author/kabata_hiroki
Author Name: Fukunaga Koichi
Author link: https://covid19-data.nist.gov/pid/rest/local/author/fukunaga_koichi
Author Name: Yamakawa Kazuma
Author link: https://covid19-data.nist.gov/pid/rest/local/author/yamakawa_kazuma
Author Name: Hayakawa Mineji
Author link: https://covid19-data.nist.gov/pid/rest/local/author/hayakawa_mineji
Author Name: Ogura Takayuki
Author link: https://covid19-data.nist.gov/pid/rest/local/author/ogura_takayuki
Author Name: Hirayama Atsushi
Author link: https://covid19-data.nist.gov/pid/rest/local/author/hirayama_atsushi
Author Name: Yasunaga Hideo
Author link: https://covid19-data.nist.gov/pid/rest/local/author/yasunaga_hideo
Author Name: Sasaki Junichi
Author link: https://covid19-data.nist.gov/pid/rest/local/author/sasaki_junichi
sha: 0566052310a912fc4e3a5655e42036fd1b3fb97b
license: cc-by
license_url: https://creativecommons.org/licenses/by/4.0/
source_x: Medline; PMC; WHO
source_x_url: https://www.medline.com/https://www.ncbi.nlm.nih.gov/pubmed/https://www.who.int/
pubmed_id: 35524282
pubmed_id_url: https://www.ncbi.nlm.nih.gov/pubmed/35524282
pmcid: PMC9073819
pmcid_url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9073819
url: https://doi.org/10.1186/s13054-022-03995-1 https://www.ncbi.nlm.nih.gov/pubmed/35524282/
has_full_text: TRUE
Keywords Extracted from Text Content: patients Patients patient coronavirus disease 2019 COVID-19 oxygen non-early [3] [4] [5] [6] [7] inpatients carbon dioxide COVID-19 PaO 2 ≥ PaO 2 alveolar ROX lung DPC patients NIPPV blood Coronavirus disease 2019 GCS patient coronavirus-2 corticosteroid D-dimer blood pulmonary Hugh-Jones arterial blood COVID-19 [35 human Coronavirus ECMO ≥ positivepressure ≥ 3 C-reactive ≥ 2 tocilizumab arterial lactate ≥ 4 FiO 2 COVD-19 Pulmonary PaCO 2 trisect lung tissue SARS-CoV-2 Patients Oxygen COVID-19 [2-5 oxygen lactate HFNC/NIPPV Blood non-early humans Patient 1186/ s13054-022 humans
Extracted Text Content in Record: First 5000 Characters:Background: Some academic organizations recommended that physicians intubate patients with COVID-19 with a relatively lower threshold of oxygen usage particularly in the early phase of pandemic. We aimed to elucidate whether early intubation is associated with decreased in-hospital mortality among patients with novel coronavirus disease 2019 (COVID-19) who required intubation. A multicenter, retrospective, observational study was conducted at 66 hospitals in Japan where patients with moderate-to-severe COVID-19 were treated between January and September 2020. Patients who were diagnosed as COVID-19 with a positive reverse-transcription polymerase chain reaction test and intubated during admission were included. Early intubation was defined as intubation conducted in the setting of ≤ 6 L/min of oxygen usage. In-hospital mortality was compared between patients with early and non-early intubation. Inverse probability weighting analyses with propensity scores were performed to adjust patient demographics, comorbidities, hemodynamic status on admission and time at intubation, medications before intubation, severity of COVID-19, and institution characteristics. Subgroup analyses were conducted on the basis of age, severity of hypoxemia at intubation, and days from admission to intubation. Results: Among 412 patients eligible for the study, 110 underwent early intubation. In-hospital mortality was lower in patients with early intubation than those with non-early intubation (18 [16.4%] vs. 88 [29.1%]; odds ratio, 0.48 [95% confidence interval 0.27-0.84]; p = 0.009, and adjusted odds ratio, 0.28 [95% confidence interval 0.19-0.42]; p < 0.001). The beneficial effects of early intubation were observed regardless of age and severity of hypoxemia at time of intubation; however, early intubation was associated with lower in-hospital mortality only among patients who were intubated later than 2 days after admission. Early intubation in the setting of ≤ 6 L/min of oxygen usage was associated with decreased in-hospital mortality among patients with COVID-19 who required intubation. Trial Registration None. Coronavirus disease 2019 (COVID-19) causes respiratory failure and often requires mechanical ventilation (MV) [1, 2] . Although several medications prevent disease progression and improve clinical outcomes [3] [4] [5] [6] [7] , many patients still die following long-term MV management. Rapid deterioration of oxygenation is also a particular feature of COVID-19, impeding physicians from determining the optimal timing of intubation [8, 9] . The idea of early intubation with relatively preserved lung function arose based on early data, where the initiation of MV after developing severe acute respiratory distress syndrome (ARDS) had devastating consequences in patients with COVID-19 [10, 11] . Avoiding self-induced lung injury due to spontaneous breathing is another pathophysiological benefit of early intubation [12] , although obvious favorable outcomes following such a strategy have not been validated [13] . Notably, some academic organizations recommended that physicians intubate patients with COVID-19 with a relatively lower threshold of oxygen usage, such as 6-8 L/min, without any scientific data [14, 15] . Given the potential benefit of early intubation, several studies compared different intubation times for respiratory failure due to COVID-19 and identified increased mortality and prolonged MV use in patients who were intubated in a later phase [16, 17] . However, most studies defined early intubation using days from admission to intubation, rather than the degree of preserved pulmonary function at the time of intubation; therefore, immortal time bias is a concern [18] . Moreover, the lack of patient characteristics at the time of intubation disturbs data interpretation, and it remains unclear whether the timing of initiation of MV simply reflects COVID-19 severity. Therefore, we examined patients with COVID-19 who required intubation using a multicenter database to elucidate the clinical benefit of early intubation, which was defined as intubation for patients with a limited amount of oxygen usage. We hypothesized that early intubation is associated with decreased in-hospital mortality among patients with COVID-19. A retrospective, multicenter, observational study was conducted by the J-RECOVER study group, which was established in 2020 to investigate multiple clinical issues related to COVID-19, using data between January and September 2020 [19] . Sixty-six hospitals, where patients with moderate-to-severe COVID-19 were treated, participated in the study. Before study initiation, collaborating hospitals obtained individual local institutional review board (IRB) approval for conducting research with human subjects. This study was approved by the IRB of the Keio University School of Medicine (application number: 20200317) for conducting research with humans. The requirement for informed consent was waived because of t
Keywords Extracted from PMC Text: inpatients COVD-19 pulmonary NIPPV DPC GCS non-early COVID-19 [ ROX D-dimer blood ≥ 4 SARS-CoV-2 trisect Blood arterial lactate Patient lung 6–8 L/min alveolar COVID-19 Coronavirus disease 2019 lactate HFNC/NIPPV patient ≥ 3 6–8 carbon C-reactive coronavirus-2 hospital- oxygen " human ≥ humans patients ≥ 2 blood corticosteroid arterial blood ECMO tocilizumab Patients FiO2 lung tissue
Extracted PMC Text Content in Record: First 5000 Characters:Coronavirus disease 2019 (COVID-19) causes respiratory failure and often requires mechanical ventilation (MV) [1, 2]. Although several medications prevent disease progression and improve clinical outcomes [3–7], many patients still die following long-term MV management. Rapid deterioration of oxygenation is also a particular feature of COVID-19, impeding physicians from determining the optimal timing of intubation [8, 9]. The idea of early intubation with relatively preserved lung function arose based on early data, where the initiation of MV after developing severe acute respiratory distress syndrome (ARDS) had devastating consequences in patients with COVID-19 [10, 11]. Avoiding self-induced lung injury due to spontaneous breathing is another pathophysiological benefit of early intubation [12], although obvious favorable outcomes following such a strategy have not been validated [13]. Notably, some academic organizations recommended that physicians intubate patients with COVID-19 with a relatively lower threshold of oxygen usage, such as 6–8 L/min, without any scientific data [14, 15]. Given the potential benefit of early intubation, several studies compared different intubation times for respiratory failure due to COVID-19 and identified increased mortality and prolonged MV use in patients who were intubated in a later phase [16, 17]. However, most studies defined early intubation using days from admission to intubation, rather than the degree of preserved pulmonary function at the time of intubation; therefore, immortal time bias is a concern [18]. Moreover, the lack of patient characteristics at the time of intubation disturbs data interpretation, and it remains unclear whether the timing of initiation of MV simply reflects COVID-19 severity. Therefore, we examined patients with COVID-19 who required intubation using a multicenter database to elucidate the clinical benefit of early intubation, which was defined as intubation for patients with a limited amount of oxygen usage. We hypothesized that early intubation is associated with decreased in-hospital mortality among patients with COVID-19. A retrospective, multicenter, observational study was conducted by the J-RECOVER study group, which was established in 2020 to investigate multiple clinical issues related to COVID-19, using data between January and September 2020 [19]. Sixty-six hospitals, where patients with moderate-to-severe COVID-19 were treated, participated in the study. Before study initiation, collaborating hospitals obtained individual local institutional review board (IRB) approval for conducting research with human subjects. This study was approved by the IRB of the Keio University School of Medicine (application number: 20200317) for conducting research with humans. The requirement for informed consent was waived because of the anonymous nature of the data used. In Japan, after sporadic COVID-19 cases were noted in January 2020, there were two surges of newly diagnosed COVID-19 cases during the study period. During those surges, several academic organizations were concerned of nosocomial infection among healthcare providers during the invasive respiratory care of patients with COVID-19, and they recommended avoiding noninvasive positive-pressure ventilation (NIPPV) and high-flow nasal cannula (HFNC) for patients with COVID-19. Additionally, physicians at some institutions preferred to intubate patients with COVID-19 with lower thresholds of oxygen usage, such as 6–8 L/min. We included patients who met the following three inclusion criteria: (1) diagnosis of COVID-19 with a positive reverse-transcription polymerase chain reaction (RT-PCR) result for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), (2) at least 18 years of age, and (3) intubated during admission. Patients were excluded if they were transferred from another health care facility after intubation or they were re-admitted for recurrent COVID-19 symptoms. Participating hospitals obtained data from medical charts and the Japanese Diagnosis Procedure Combination (DPC) records at each hospital [20]. DPC is used for administrative claims and, therefore, includes demographic data; diagnosis at admission, comorbidities, and post-admission complications that are coded with the International Classification of Diseases, 10th Revision; chronic cardiopulmonary status, including Hugh–Jones and New York Heart Association (NYHA) functional classifications; treatments provided during hospitalization, including medications, blood products, surgery, and interventional procedures, along with dose and date; and discharge abstract data. Data are recorded using a uniform data submission format across the country, and physicians at each institution are mandated to confirm that data are correctly submitted with reference to medical charts. As DPC is a record for inpatients, data after hospital discharge are not available. Data were also obtained from medical charts that included the f
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