Characteristics and Outcomes of Emergent Endotracheal Intubation During the Novel Coronavirus 2019 Pandemic

Abstract

Introduction: Both international and institutional guidelines regarding intubation practices during the COVID-19 pandemic advocate for interventions that maximize first pass success and minimize infectious risk to operators. The impact of the advocated practice changes remains unknown. We conducted a retrospective study to determine how the COVID-19 pandemic has changed outcomes associated with emergent endotracheal intubation (EEI). Methods: We conducted a retrospective cohort study examining patients admitted to Montefiore Medical Center (Bronx, NY) between July 19, 2019 and May 1, 2020. Patients were eligible for inclusion if they underwent an EEI performed outside the operating room by the critical care service. Exclusion criteria included intubations performed in the emergency room, pediatric patients or repeat intubations of the same patient. The patient cohort was split into a pandemic group undergoing intubation after March 11, 2020 and a historical control group intubated prior to this date. The primary outcome was the rate of first pass success (FPS). Secondary outcomes included periprocedural adverse events and mortality within 24 hours following the procedure. Logistic regression was used to compare the primary outcome against the exposure variable with correction for potential confounders. Results: The final cohort consisted of 478 patients undergoing EEI during the pandemic and 782 prior to the pandemic. Baseline characteristics are summarized in Table 1. During the pandemic, operators were more likely to utilize neuromuscular blockade (86.0% vs 46.2%;P<0.001), video laryngoscopy (89.3% vs 53.3%;P<0.001) and sedation (90.1% vs 77.8%;P<0.001). FPS occurred more frequently during the pandemic (96.4% vs 82.9%, OR 5.61, 95%CI: 3.34-9.42;P<0.001). The higher rate of FPS persisted after multivariable adjustment (adjusted OR 4.40, 95%CI: 2.46-7.87;P<0.001). Patients undergoing intubation during the pandemic were more likely to have a periprocedural complication (29.1% vs 14.1%, adjusted OR 2.16, 95%CI: 1.46-3.18;P<0.001) which was mainly driven by hypoxemia (25.7% vs 8.2%, adjusted OR 2.78, 95%CI: 1.78-4.35;P<0.001). There was no difference in the 24-hour mortality rate during the pandemic (19.3% vs 18.3%, adjusted OR 1.26, 95%CI: 0.86-1.84;P=0.23). Conclusions: Emergency intubation during the COVID-19 pandemic was associated with a higher rate of FPS. This improved procedural success may in part be attributed to changes in intubation practice. The observed practice changes and improved procedural success did not correlate with improvement in peri-procedural adverse events, an observation that may stem from the differences between the studied cohorts such as the tendency of patients with COVID-19 to be prone to hypoxemia. (Table Presented).