Abstract
Purpose:We sought to identify clinical factors that predict extubation failure (reintubation) and its prognostic implications in critically ill COVID-19 patients.Materials and Methods:Retrospective, multi-center cohort study of hospitalized COVID-19 patients. Multivariate competing risk models were employed to explore the rate of reintubation and its determining factors.Results:Two hundred eighty-one extubated patients were included (mean age, 61.0 years [±13.9]; 54.8% male). Reintubation occurred in 93 (33.1%). In multivariate analysis accounting for death, reintubation risk increased with age (hazard ratio [HR] 1.04 per 1-year increase, 95% confidence interval [CI] 1.02 -1.06), vasopressors (HR 1.84, 95% CI 1.04-3.60), renal replacement (HR 2.01, 95% CI 1.22-3.29), maximum PEEP (HR 1.07 per 1-unit increase, 95% CI 1.02 -1.12), paralytics (HR 1.48, 95% CI 1.08-2.25) and requiring more than nasal cannula immediately post-extubation (HR 2.19, 95% CI 1.37-3.50). Reintubation was associated with higher mortality (36.6% vs 2.1%; P < 0.0001) and risk of inpatient death after adjusting for multiple factors (HR 23.2, 95% CI 6.45-83.33). Prone ventilation, corticosteroids, anticoagulation, remdesivir and tocilizumab did not impact the risk of reintubation or death.Conclusions:Up to 1 in 3 critically ill COVID-19 patients required reintubation. Older age, paralytics, high PEEP, need for greater respiratory support following extubation and non-pulmonary organ failure predicted reintubation. Extubation failure strongly predicted adverse outcomes.
Highlights
In its most severe form, coronavirus disease 2019 (COVID-19) caused by the novel pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to an acute respiratory distress syndrome requiring invasive mechanical ventilation
We hypothesize that the risk of extubation failure in COVID-19 is increased by disease severity, either pulmonary or extrapulmonary
Over 7 months, there were 5632 consecutive patients admitted to our hospital system who tested positive for COVID-19
Summary
In its most severe form, coronavirus disease 2019 (COVID-19) caused by the novel pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to an acute respiratory distress syndrome requiring invasive mechanical ventilation. Up to one half of patients exhibit a protracted clinical course marked by prolonged need for mechanical ventilation and less than half of intubated patients are safely liberated from the ventilator during their hospital stay.[1,2,3,4] early reports indicate the success rate of extubation success is low, with as many as 1 in 6 patients requiring reintubation within 7 days.[1,2]. There is currently limited data to characterize the risk of extubation failure (reintubation) in COVID-19 patients. The impact on the risk of extubation failure and on in-hospital mortality of the clinical experience gained since wide adoption of corticosteroids, therapeutic anticoagulation, and antivirals in critically ill COVID-19 patients remains unknown. We hypothesize that the risk of extubation failure in COVID-19 is increased by disease severity, either pulmonary (high positive end-expiratory pressure requirement or need for salvage therapies) or extrapulmonary (need for vasopressor support or renal replacement therapy).
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