Early Intubation Research Articles

Airway Management in Patients With Severe Traumatic Brain Injuries in the Emergency Unit: Integratva Review

Objective: The present study aims to analyze the best practices, risk factors, and challenges involved in airway management in patients with severe TBI, both in the prehospital and hospital settings, in order to identify interventions that optimize clinical outcomes. Method: An integrative literature review was conducted based on studies published between 2019 and 2024. The research was structured by the PICo (Population, Interest and Context) strategy, focusing on patients with severe TBI, airway management and ventilation. After screening 325 articles, 10 studies were selected for critical analysis, following the PRISMA guidelines. Results and Discussion: It was observed that early intubation, although crucial, presents significant variations in effectiveness depending on the training and experience of the team. Complications such as excessive hyperventilation, aspiration, and difficulties in airway management in patients with cervical spine injuries were recurrent in the studies. The implementation of standardized protocols and the use of advanced devices, such as videolaryngoscopy, have been identified as essential measures to reduce complications and improve outcomes. The need for a trained multidisciplinary team and the use of evidence-based guidelines was also highlighted as critical to treatment success. Conclusion: Airway management in patients with severe TBI is complex and requires a careful and well-trained approach. The review emphasizes the importance of well-defined protocols and continuous training of emergency responders to optimize survival and neurological outcomes for these patients.

Effect of timing of intubation on clinical outcomes of patients with septic shock: a retrospective cohort study.

Evidence-based data regarding the timing of the application of invasive mechanical ventilation among adults with septic shock is insufficient. The guidelines fail to provide clear advice about the optimal time to initiate this support. Consequently, we aimed to investigate whether early intubation could improve survival rates in septic shock patients. We conducted a retrospective analysis of the MIMIC-IV database to evaluate the effectiveness of early intubation on mortality in a cohort of septic shock patients. Adults diagnosed with septic shock, according to the Sepsis-3 definition, were included. They were categorized into an early intubation group (first 8h after vasopressor initiation) and a non-early intubation group (unexposed). A propensity score matching (PSM) analysis was used to balance the baseline characteristics between the two groups. The primary outcomes were 30-day and 90-day all-cause mortality rates. In addition, we employed the restricted cubic spline to analyze the potential non-linear relationship between the timing of intubation and 30-day or 90-day all-cause mortality. A total of 6864 adult patients, of whom 2048 were intubated in the first 8h, were evaluated in the final cohort. Following a 1:1 PSM procedure, 2786 patients were successfully paired. At 30days, 288 of 1393 patients (20.7%) in the early intubation group and 381 of 1393 patients (27.4%) in the non-early intubation group had died (hazard ratio [HR] 0.717; 95% confidence interval [CI] 0.616-0.836; p < 0.001). Similarly, the results also showed that early intubation was associated with a lower 90day all-cause mortality rate (HR 0.761; 95% CI 0.663-0.874; p < 0.001). Furthermore, ICU and hospital lengths of stay were significantly different between the groups (3.6 [1.9, 7.1] vs. 2.3 [1.3, 4.3]; p < 0.001 and 8.9 [5.4, 15.1] vs. 7.2 [4.5, 12.0]; p < 0.001). In the subgroup analysis, we further confirmed the robustness of our findings. Additionally, we found that the timing of intubation is inversely U-shaped correlated to the 30day all-cause mortality rate. Among adult patients with septic shock, the early initiation of invasive mechanical ventilation could improve clinical outcomes. The timing of intubation demonstrated an inverse U-shaped association with the 30day all-cause mortality rate, with the peak risk of death occurring at 50.5h after septic shock.

Screening of Palatopharyngeal Incoordination in Mechanically Ventilated Critically Ill Infants

Abstract Background Palatopharyngeal incoordination is a common phenomenon in patients requiring endotracheal intubation for mechanical ventilation. Understanding the underlying mechanism of palatopharyngeal incoordination may help as a screening tool that improves rates of early recognition and diagnosis and the ability to take preventive measures essential to alleviate related morbidity and complications. Objective The aim of this study is to screen palatopharyngeal incoordination in infants who needed mechanical ventilation and to elicit palatopharyngeal incoordination secondary to mechanical ventilation. Material and Methods This study included 51 patients at the Pediatric Intensive Care Unit, Faculty of Medicine, Ain Shams University, The study was conducted during the period from February 2021 to February 2022. patients were classified according to a Fiberoptic Flexible Endoscopic Evaluation of Swallowing (FEES) early post intubation, FEES early post extubation, Videofluoroscopic Swallow Study (VFSS) post extubation and dye study into five groups: group (1) the not affected group, group (2) the palatopharyngeal incoordination group, group (3) The palatopharyngeal incoordination with gastro esophageal reflux group, group (4) The reflux group, group (5) The congenital upper air way anomalies group in which patients were ventilated due to respiratory distress. Follow up FEES and VFSS were done after three months for palatopharyngeal incoordination patients. Results Palatopharyngeal incoordination was detected in 16 patients (31.3%), congenital upper airway anomalies were found in 12 patients (23.5%), and gastroesophageal reflux was only detected in 10 patients (19.6%). Performing VFSS and FEES after three months showed 92.3 % of palatopharyngeal incoordination patients had resolved palatopharyngeal incoordination and 7.7 % of palatopharyngeal incoordination patients had silent aspiration. Conclusion The prevalence of palatopharyngeal incoordination is 31.3 % and there was no palatopharyngeal incoordination secondary to mechanical ventilation.

Intubation and In-Hospital Mortality After Trauma With Glasgow Coma Scale Score Eight or Less–A Cohort Study

IntroductionMost trauma societies recommend intubating trauma patients with Glasgow Coma Scale (GCS) scores ≤8 without robust supporting evidence. We examined the association between intubation and 30-d in-hospital mortality in trauma patients arriving with a GCS score ≤8 in an Indian trauma registry. MethodsOutcomes of patients with a GCS score ≤8 who were intubated within 1 h of arrival (intubation group) were compared with those who were intubated later or not at all (nonintubation group) using various analytical approaches. The association was assessed in various subgroup and sensitivity analyses to identify any variability of the effect. ResultsOf 3476 patients who arrived with a GCS score ≤8, 1671 (48.1%) were intubated within 1 h. Overall, 1957 (56.3%) patients died, 947 (56.7%) in the intubation group and 1010 (56.0%) in the nonintubation group, with no significant difference in mortality (odds ratio = 1.2 [confidence interval, 0.8-1.8], P value = 0.467) in multivariable regression and propensity score-matched analysis. This result persisted across subgroup and sensitivity analyses. Patients intubated within an hour of arrival had longer durations of ventilation, intensive care unit stay, and hospital stay (P < 0.001). ConclusionsIntubation within an hour of arrival with a GCS score ≤8 after major trauma was not associated with differences in-hospital mortality. The indications and benefits of early intubation in these severely injured patients should be revisited to promote optimal resource utilization in LMICs.

Outcome of early emergency intubation and early emergency dialysis in deliberate self-harm with formic acid in a tertiary care center in South India: A retrospective cohort study.

The objective is to evaluate the outcome of early emergency intubation and early dialysis in formic acid (FA) poisoning and to determine the clinical features associated with its mortality. It is a retrospective cohort study of 78 patients who presented to the emergency medicine department from July 2008 to June 2015 with alleged history and clinical features of FA poisoning. The outcome of early intubation and early dialysis was studied in terms of 7-day and 30-day mortality. The outcome was compared in severe and not severe groups separately. Severity was graded according to Med-Tu chart used for corrosive poisoning. In the severe group (n = 53), early dialysis was done in 15 patients. There was 53% (n = 8) 30-day mortality. In the group where early dialysis was not done there was a significant increase in mortality 92.1% (n = 35). This was statistically significant with a P = 0.003. In a similar fashion 7-day mortality was analyzed in the severe group where mortality was higher when early dialysis was not done. In not severe group early dialysis has minimally decreased the mortality. Early intubation in severe group did not demonstrate any mortality benefit. Patients who were intubated early and not intubated early had equally high mortality. In not severe group, intubation could not make any significant difference in mortality. In this retrospective study, we observed that early dialysis in the severe group has a better outcome in terms of 7-day and 30-day mortality.

Effects of bradycardia, hypoxemia and early intubation on bronchopulmonary dysplasia in very preterm infants: An observational study

BackgroundBronchopulmonary dysplasia (BPD) is the most common pulmonary complication in preterm infants. ObjectivesThe study aimed to explore the effects of bradycardia, hypoxemia, and early intubation on BPD in very preterm infants. MethodsThis is a prospective observational cohort study. Preterm infants with a mean gestational age of 28.67 weeks were recruited from two level III neonatal intensive care units (NICUs) in Taiwan. Continuous electrocardiography was used to monitor heart rates and oxygen saturation (SpO2). Infants were monitored for heart rates of <100 beats per minute and SpO2 levels of <90 % lasting for 30 s. Generalized estimating equations were used to analyze the effects of bradycardia, hypoxemia, and early intubation on BPD in very preterm infants. Model fit was visually assessed using receiver operating characteristic curve analysis. ResultsBradycardia, hypoxemia, and early intubation significantly increased the odds of BPD among the preterm infants (N = 39) during NICU stay; the odds ratios for bradycardia, hypoxemia, and early intubation for BPD versus non-BPD were 1.058, 1.013, and 29.631, respectively (all p < 0.05). A model combining bradycardia, hypoxemia, and early intubation accurately predicted BPD development (area under the curve = 0.919). ConclusionsBradycardia, hypoxemia, and early intubation significantly increased the odds of BPD among very preterm infants during NICU stay. The model combining bradycardia, hypoxemia, and early intubation accurately predicted BPD development.

Intubation Decision Based on Illness Severity and Mortality in COVID-19: An International Study.

To evaluate the impact of intubation timing, guided by severity criteria, on mortality in critically ill COVID-19 patients, amidst existing uncertainties regarding optimal intubation practices. Prospective, multicenter, observational study conducted from February 1, 2020, to November 1, 2022. Ten academic institutions in the United States and Europe. Adults (≥ 18 yr old) confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hospitalized specifically for COVID-19, requiring intubation postadmission. Exclusion criteria included patients hospitalized for non-COVID-19 reasons despite a positive SARS-CoV-2 test. Early invasive mechanical ventilation (EIMV) was defined as intubation in patients with less severe organ dysfunction (Sequential Organ Failure Assessment [SOFA] < 7 or Pa o2 /F io2 ratio > 250), whereas late invasive mechanical ventilation (LIMV) was defined as intubation in patients with SOFA greater than or equal to 7 and Pa o2 /F io2 ratio less than or equal to 250. The primary outcome was mortality within 30 days of hospital admission. Among 4464 patients, 854 (19.1%) required mechanical ventilation (mean age 60 yr, 61.7% male, 19.3% Black). Of those, 621 (72.7%) were categorized in the EIMV group and 233 (27.3%) in the LIMV group. Death within 30 days after admission occurred in 278 patients (42.2%) in the EIMV and 88 patients (46.6%) in the LIMV group ( p = 0.28). An inverse probability-of-treatment weighting analysis revealed a statistically significant association with mortality, with patients in the EIMV group being 32% less likely to die either within 30 days of admission (adjusted hazard ratio [HR] 0.68; 95% CI, 0.52-0.90; p = 0.008) or within 30 days after intubation irrespective of its timing from admission (adjusted HR 0.70; 95% CI, 0.51-0.90; p = 0.006). In severe COVID-19 cases, an early intubation strategy, guided by specific severity criteria, is associated with a reduced risk of death. These findings underscore the importance of timely intervention based on objective severity assessments.

The Role of Early Intubation in Status Epilepticus with Out-of-Hospital Onset: A Large Prospective Observational Study.

Background: this study aimed to evaluate the role of early airway management and intubation in status epilepticus (SE) with out-of-hospital onset. Methods: We included all patients with out-of-hospital SE onset referred to the emergency department of the Academic Hospital of Modena between 2013 and 2021. Patients were compared according to out-of-hospital airway management (intubation versus non-intubation) and a propensity score was performed for clinical variables unevenly distributed between the two groups. Results: We evaluated 711 patients with SE. A total of 397 patients with out-of-hospital SE onset were eventually included; of these, 20.4% (81/397) were intubated before arrival at the hospital. No difference was found in the clinical characteristics of patients after propensity score matching. The 30-day mortality in the propensity group was 19.4% (14/72), and no difference was found between intubated (7/36, 19.4%) and non-intubated (7/36, 19.4%) patients. No difference was found in SE cessation. Compared to non-intubated patients, those who underwent out-of-hospital intubation had a higher risk of progression to refractory or super-refractory SE, greater worsening of mRS values between hospital discharge and admission, and lower probability of returning to baseline condition at 30 days after SE onset. Conclusions: Early intubation for out-of-hospital SE onset is not associated with improved patient survival even after balancing for possible confounders. Further studies should evaluate the timing of intubation and its association with first-line treatments for SE and their efficacy. In addition, they should focus on the settings and the exact reasons leading to intubation to better inform early management of SE with out-of-hospital onset.

Differences in clinical outcomes and resource utilization in pediatric traumatic brain injury between countries of different sociodemographic indices.

The burden of traumatic brain injury (TBI) is disproportionately high in low- and middle-income countries (LMICs). This study aimed to compare clinical outcomes and healthcare utilization for children with moderate to severe TBIs between LMICs and non-LMICs in Asia and Latin America. The authors performed an observational multicenter study from January 2014 to February 2023 among children with moderate to severe TBIs admitted to participating pediatric intensive care units (PICUs) in the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) and Red Colaborativa Pediátrica de Latinoamérica (LARed Network). They classified sites according to their 2019 sociodemographic index (SDI). Low, low-middle, and middle SDI sites were considered LMICs, while high-middle and high SDI sites were considered non-LMICs. The authors documented patient demographics and TBI management. Accounting for death, they recorded 14-day PICU-free and 28-day hospital-free days, with fewer free days indicating poorer outcome. The authors compared children who died and those who had poor functional outcomes (defined as Pediatric Cerebral Performance Category [PCPC] level of moderate disability, severe disability, or vegetative state or coma) between LMICs and non-LMICs and performed a multivariable logistic regression analysis for predicting poor functional outcomes. In total, 771 children with TBIs were analyzed. Mortality was comparable between LMICs and non-LMICs (9.6% vs 12.9%, p = 0.146). Children with TBIs from LMICs were more likely to have a poor PCPC outcome (31.0% vs 21.3%, p = 0.004) and had fewer ICU-free days (median [IQR] 6 [0-10] days vs 8 [0-11] days, p = 0.004) and hospital-free days (median [IQR] 9 [0-18] days vs 13 [0-20] days, p = 0.007). Poor functional outcomes were associated with LMIC status (adjusted OR [aOR] 1.53, 95% CI 1.04-2.26), a lower Glasgow Coma Scale score (aOR 0.83, 95% CI 0.78-0.88), and the presence of multiple trauma (aOR 1.49, 95% CI 1.01-2.19). Children with TBIs in LMICs required greater resource utilization in the form of early intubation and mechanical ventilation (81.6% vs 73.2%, p = 0.006), use of hyperosmolar therapy (77.7% vs 63.6%, p < 0.001), and use of antiepileptic drugs (73.9% vs 53.1%, p < 0.001). Within Asia and Latin America, children with TBIs in LMICs were more likely to have poor functional outcomes and required greater resource utilization. Further research should focus on investigating causal factors and developing targeted interventions to mitigate these disparities.

Early endotracheal intubation is not associated with the rate of return of spontaneous circulation following cardiac arrest at the emergency department: an exploratory analysis.

Early endotracheal intubation is not associated with the rate of return of spontaneous circulation following cardiac arrest at the emergency department: an exploratory analysis.

Refractory Hypoglycemia with Generalized Convulsive Status Epilepticus in Suspected Propranolol Overdose: Is Early Intubation the Key?

There are many ways to manage status epilepticus. The rationale for aggressive treatment of generalized convulsive status epilepticus lies solely on the premise that best outcomes rely upon rapid seizure control. Metabolic and toxic seizures can be particularly refractory to therapy, exposing a patient to the threat of aspiration, hyperkalemia, rhabdomyolysis, hyperthermia, myocardial infarction, and arrhythmias.1 The role of intubation is controversial. Neurologists tend to view intubation as a form of “treatment failure”, reflecting inability to treat the seizure with traditional agents.1 However, it is our opinion that intubation is often the key therapeutic intervention to not only control the seizure, but prevent its deadly complications. In our case report, we highlight the emergent airway management of a 29-year-old pre-morbidly healthy female who was referred to us from a secondary care center with generalized convulsive status epilepticus and refractory hypoglycemia, following an alleged history of propranolol overdose.

DIFFERENCES IN MANAGEMENT AND PROGNOSTICATION OF CARDIOGENIC SHOCK PATIENTS IN THE PRESENCE AND ABSENCE OF OUT-OF-HOSPITAL CARDIAC ARREST.

Background: The clinical spectrum of acute myocardial infarction complicated by cardiogenic shock (AMICS) varies. Out-of-hospital cardiac arrest (OHCA) can be the first sign of cardiac failure, whereas others present with various degrees of hemodynamic instability (non-OHCA). The aim of the present study was to explore differences in prehospital management and characteristics of survivors and nonsurvivors in AMICS patients with OHCA or non-OHCA. Methods: Data analysis was based on patient data from the RETROSHOCK cohort comprising consecutive AMICS patients admitted to two tertiary cardiac centers between 2010 and 2017. Results: 1,716 AMICS patients were included and 42% presented with OHCA. Mortality in OHCA patients was 47% versus 57% in the non-OHCA group. Almost all OHCA patients were intubated before admission (96%). In the non-OHCA group, prehospital intubation (25%) was associated with a better survival ( P < 0.001). Lactate level on admission demonstrated a linear relationship with mortality in OHCA patients. In non-OHCA, probability of death was higher for any given lactate level <12 mmol/L compared with OHCA. However, a lactate level >7 mmol/L in non-OHCA did not increase mortality odds any further. Conclusion: Mortality was almost doubled for any admission lactate level up to 7 mmol/L in non-OHCA patients. Above this level, mortality remained unchanged in non-OHCA patients but continued to increase in OHCA patients. Prehospital intubation was performed in almost all OHCA patients but only in one of four patients without OHCA. Early intubation in non-OHCA patients was associated with a better outcome.

Oropharyngeal Hemorrhage and Difficult Airway Management: A Decision Not to Intubate

BackgroundBleeding in the upper airways is an important cause of airway-related death. A higher incidence of airway management failure and complications after intubation attempts in the emergency department (ED) had been suggested. Airway management of patients with active oropharyngeal hemorrhage may be challenging, leading the clinician to modify the approach. Case ReportA 57-year-old woman presented to the ED with oropharyngeal hemorrhage after an extensive invasive dental procedure. She was on long-term warfarin therapy due to aortic and mitral valve replacement, which she suspended 5 days prior and restarted the day after the procedure. Besides the active bleeding, swelling, and hematoma of the face, the patient had other signs of “difficult airway,” so there were serious questions on when and how to manage the airway. Several strategies to address the airway were considered, the main point being an early versus later intubation. As the patient remained clinically stable, she was conservatively managed with local hemostasis and coagulopathy reversal. The patient was transferred to the intensive care unit, where she remained stable and was successfully discharged after restart on warfarin. Why Should an Emergency Physician Be Aware of This?When faced with an oropharyngeal hemorrhage, emergency physicians may be compelled to secure and protect the airway. This could be achieved by planning several strategies. Nevertheless, in selected patients, and considering the circumstances, not addressing the airway is a reasonable and justifiable alternative.

Impact of Respiratory Bacterial Codetection on Outcomes in Ventilated Infants With Bronchiolitis.

Viral bronchiolitis is a common cause of acute respiratory failure requiring intubation for infants. Bacterial respiratory tract infections can occur with bronchiolitis, although their prevalence and impact on outcomes are unclear, especially with increased use of noninvasive respiratory support. This was a single-center retrospective cohort study of children <2 years old requiring intubation in the emergency department for bronchiolitis from 2012 to 2017 who had viral testing plus a lower respiratory culture obtained. We evaluated the impact of bacterial codetection (positive respiratory culture plus moderate or many polymorphonuclear neutrophils on Gram stain) on mechanical ventilation (MV) duration and intensive care unit length of stay using multivariable gamma regression. Of 149 patients enrolled, 52% had bacterial codetection. In adjusted analysis, patients with codetection had shorter MV duration [adjusted relative risk (aRR) 0.819, 95% confidence interval (CI): 0.69-0.98; marginal mean duration of 5.31 days (4.71-5.99) compared to 6.48 days (5.72-7.35) without codetection]. Patients with codetection had a shorter intensive care unit stay [aRR 0.806 (0.69-0.94); marginal mean length of stay 6.9 days (6.21-7.68) vs. 8.57 days (7.68-9.56) without codetection]. The association between codetection and duration of ventilation appears confined to those receiving earlier antibiotics (less than the median time) rather than later antibiotics [aRR 0.738 (0.56-0.95) for earlier vs. aRR 0.92 (0.70-1.18) for later]. Respiratory bacterial codetection is common and associated with shorter MV duration in infants requiring early intubation for bronchiolitis. Early antibiotics may contribute to these outcomes, but further multicenter studies are needed to understand the role of codetection and antibiotics on bronchiolitis outcomes.

Early Versus Late Endotracheal Intubation in Subjects with COVID-19 Pneumonia Treated with High-Flow Oxygen: A Retrospective Observational Study.

The availability of high-flow oxygen (HFO) machines allowed patients with COVID-19 pneumonia to be comfortably treated for longer periods of time until endotracheal intubation became inevitable. Patients treated with invasive mechanical ventilation (MV) preceded by HFO treatment may continue to progress and die. Hence there is a belief in physicians that patients treated with HFO might have delayed invasive MV. The study was conducted as a retrospective review of subjects with confirmed COVID-19 admitted to the Dubai Hospital ICU. Study variables included time to intubation, duration of HFO, and cumulative duration of tachypnea and tachycardia while on HFO usage. Early intubation was defined as within 24 hours of the start of HFO, and late intubation was defined as after seven days on HFO. Groups were compared for outcome measures; mortality and length of stay (LOS) in the ICUand hospital. Clinical outcomes of mortality and LOS in ICU and hospital were not significantly different among patients intubated early versus late. Duration of tachypnea and tachycardia was also not different comparing patients intubated early versus late. There was no significant difference in clinical outcomes in patients intubated early versus late in patients treated with HFO for COVID-19 pneumonia.

Association Between High-Level D-Dimer at Admission and Early Intubation in Patients With Moderate Traumatic Brain Injury.

It is unclear who can benefit from tracheal intubation in the moderate (mTBI) traumatic brain injury (TBI) population. Given that mTBI patients are conscious, intubation can cause intense stress, possibly triggering neurological deterioration. Therefore, identifying potential risk factors for intubation in mTBI patients can serve as a valuable clinical warning. We sought to investigate whether elevated D-dimer is a possible risk factor for intubation in mTBI patients. Using the STROBE statement, adult patients with isolated TBI (Glasgow Coma Scale [GCS] score 9-13) treated at a high-volume neurotrauma center between January 2015 and December 2020 were reviewed. The demographics, clinical presentation, neuroimaging, and laboratory information were collected based on the patients' electronic medical record. D-dimer values were assessed from serum when patients were admitted to the hospital. The primary study end-point was that the mTBI patient was intubated within 72 h upon admission. A total of 557 patients with mTBI were finally included in this study. Of these, 85 (15.3%) patients were intubated. Multi-variate logistic regression analysis showed that high-level D-dimer (≥17.9mg/L) was significantly associated with early tracheal intubation in mTBI patients (odds ratio, 3.10 [1.16-8.25]; p = 0.024) after adjusting for age, sex, GCS scores, Marshall scores, and Injury Severity Scores. Sensitivity analysis showed that high-level D-dimer had a robust correlation with intubation in the different subgroups or after propensity score matching. High-level D-dimer on admission is an independent risk factor for early tracheal intubation in isolated mTBI patients.

Long-Term Radiological Pulmonary Changes in Mechanically Ventilated Patients with Respiratory Failure due to SARS-CoV-2 Infection.

From the first reports of SARS-CoV-2, at the end of 2019 to the present, the global mortality associated with COVID-19 has reached 6,952,522 deaths as reported by the World Health Organization (WHO). Early intubation and mechanical ventilation can increase the survival rate of critically ill patients. This prospective study was carried out on 885 patients in the ICU of Mureș County Clinical Hospital, Romania. After applying inclusion and exclusion criteria, a total of 54 patients were included. Patients were monitored during hospitalization and at 6-month follow-up. We analyzed the relationship between invasive mechanical ventilation (IMV) and non-invasive mechanical ventilation (NIMV) and radiological changes on thoracic CT scans performed at 6-month follow-up and found no significant association. Regarding paraclinical analysis, there was a statistically significant association between patients grouped by IMV and ferritin level on day 1 of admission (p = 0.034), and between patients grouped by PaO2/FiO2 ratio with metabolic syndrome (p = 0.03) and the level of procalcitonin (p = 0.01). A significant proportion of patients with COVID-19 admitted to the ICU developed pulmonary fibrosis as observed at a 6-month evaluation. Patients with oxygen supplementation or mechanical ventilation require dynamic monitoring and radiological investigations, as there is a possibility of long-term pulmonary fibrosis that requires pharmacological interventions and finding new therapeutic alternatives.

Analysis of an Individualised Stepwise Approach to Non-Pharmacological Therapy in COVID-19

Background: Early intubation versus use of conventional or high-flow nasal cannula oxygen therapy (COT/HFNC), continuous positive airway pressure (CPAP), and non-invasive ventilation (NIV) has been debated throughout the COVID-19 pandemic. Our centre followed a stepwise approach, in concordance with German national guidelines, escalating non-invasive modalities prior to invasive mechanical ventilation (IMV) or extracorporeal membrane oxygenation (ECMO), rather than early or late intubation. Objectives: The aims of the study were to investigate the real-life usage of these modalities and analyse patient characteristics and survival. Method: A retrospective monocentric observation was conducted of all consecutive COVID-19 hospital admissions between March 2020 and December 2021 at a university-affiliated pulmonary centre in Germany. Anthropometric data, therapy, and survival status were descriptively analysed. Results: From 1,052 COVID-19-related admissions, 835 patients were included (54% male, median 58 years). Maximum therapy was as follows: 34% (n = 284) no therapy, 40% (n = 337) COT, 3% (n = 22) HFNC, 9% (n = 73) CPAP, 7% (n = 56) NIV, 4% (n = 34) IMV, and 3% (n = 29) ECMO. Of 551 patients treated with at least COT, 12.3% required intubation. Overall, 183 patients required intensive unit care, and 106 (13%) died. Of the 68 patients who received IMV/ECMO, 48 died (74%). The strategy for non-pharmacological therapy was individual but remained consistent throughout the studied period. Conclusions: This study provides valuable insight into COVID-19 care in Germany and shows how the majority of patients could be treated with the maximum treatment required according to disease severity following the national algorithm. Escalation of therapy modality is interlinked with disease severity and thus associated with mortality.

Volumetric capnography and return of spontaneous circulation in an experimental model of pediatric asphyxial cardiac arrest

A secondary analysis of a randomized study was performed to study the relationship between volumetric capnography (VCAP) and arterial CO2 partial pressure (PCO2) during cardiopulmonary resuscitation (CPR) and to analyze the ability of these parameters to predict the return of spontaneous circulation (ROSC) in a pediatric animal model of asphyxial cardiac arrest (CA). Asphyxial CA was induced by sedation, muscle relaxation and extubation. CPR was started 2 min after CA occurred. Airway management was performed with early endotracheal intubation or bag-mask ventilation, according to randomization group. CPR was continued until ROSC or 24 min of resuscitation. End-tidal carbondioxide (EtCO2), CO2 production (VCO2), and EtCO2/VCO2/kg ratio were continuously recorded.Seventy-nine piglets were included, 26 (32.9%) of whom achieved ROSC. EtCO2 was the best predictor of ROSC (AUC 0.72, p < 0.01 and optimal cutoff point of 21.6 mmHg). No statistical differences were obtained regarding VCO2, VCO2/kg and EtCO2/VCO2/kg ratios. VCO2 and VCO2/kg showed an inverse correlation with PCO2, with a higher correlation coefficient as resuscitation progressed. EtCO2 also had an inverse correlation with PCO2 from minute 18 to 24 of resuscitation. Our findings suggest that EtCO2 is the best VCAP-derived parameter for predicting ROSC. EtCO2 and VCO2 showed an inverse correlation with PCO2. Therefore, these parameters are not adequate to measure ventilation during CPR.

The optimal time for endotracheal intubation in subjects with coronavirus disease 2019 pneumonia: A retrospective observational study.

The optimal timing of intubation has been debated among healthcare professionals, current studies do not show any differences between early and late intubation. most studies failed to show any significant difference in clinical outcomes between early or late intubation. The study was conducted as a retrospective review of subjects with confirmed coronavirus disease 2019 admitted to the Dubai Hospital intensive care unit (ICU). Study variables included time to intubation, duration of supplemental oxygen requirement >15 L/min, and cumulative duration of tachypnea and tachycardia while on the aforementioned oxygen requirement on this oxygen usage level. Each time duration was assessed for correlation with clinical variables including mortality and length of stay in ICU and hospital. Subjects who require endotracheal intubation within 4 h after the start of oxygen >15 L/min have lower survival (P = 0.03). Subjects who have tachypnea on the aforementioned oxygen requirement for 6-19.5 h (P = 0.01) before they require intubation have better survival. No duration of tachycardia has any significant effect on survival. Only the duration of invasive mechanical ventilation (MV) correlated with the hospital length of stay. Subjects who require endotracheal intubation within 4 h after the start of oxygen >15 L/min have lower survival. The optimal time for intubation is after tachypnea of 6 h but before 19.5 h. No duration of tachycardia has any significant effect on survival. Only the duration of invasive MV correlated with the hospital length of stay.