Acute hypoxaemic respiratory failure is a major manifestation of severe COVID-19 and requires immediate respiratory support. The optimal timing of intubation remained challenging for many reasons. Delayed intubation may have been associated with a poorer prognosis, partly because of prolonged use of non-invasive ventilation on inflamed lungs, promoting self-inflicted lung injury. The appropriate management approach to respiratory failure in COVID-19 has not yet been established and few studies have investigated the effect of the timing of intubation and whether it affects patient outcomes. In order to assess whether the timing of intubation was associated with differences in mortality, a retrospective observational study was conducted.
217 COVID-19 patients who were intubated were included in the study. It was observed that the duration between hospital admission and intubation was independently associated with ICU mortality, particularly when patients were intubated after 7 days. The association between the duration of non-invasive ventilatory support before intubation and mortality in our study may be explained by the selection of patients with more severe lung inflammation and failure who were ultimately admitted to the ICU. Interestingly, it has been shown that non-invasive ventilation may generate large tidal volumes in patients with ARDS and therefore induce volutrauma. It can therefore be postulated that patients with prolonged respiratory failure kept extubated for a long period of time may have generated lung injury due to high tidal volumes, in addition to that induced by viral pneumonia and alveolar inflammation.
In conclusion, the present study suggests that delaying ICU admission and intubation could be potentially harmful and associated with increased mortality. Further randomised controlled trials are needed to provide key information about the optimal time of ICU admission and intubation.
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