Bavishi Avni A, Mylvaganam Ruben J, Agarwal Rishi, Avery Ryan J, Cuttica Michael J
Division of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
Crit Care Explor. 2021 May 12;3(5):e0415. doi: 10.1097/CCE.0000000000000415. eCollection 2021 May.
Determine the variation in outcomes and respiratory mechanics between the subjects who are intubated earlier versus later in their coronavirus disease 2019 course.
Retrospective cohort study.
Northwestern Memorial Hospital ICUs.
All patients intubated for coronavirus disease 2019 between March 2020 and June 2020.
Patients were stratified by time to intubation: 30 subjects were intubated 4-24 hours after presentation and 24 subjects were intubated 5-10 days after presentation. Baseline characteristics, hospitalization, ventilator mechanics, and outcomes were extracted and analyzed. Ten clinically available CT scans were manually reviewed to identify evidence of pulmonary vascular thrombosis and intussusceptive angiogenesis.
Median time from symptom onset to intubation was significantly different between the early and late intubation cohorts, with the latter being intubated later in the course of their illness (7.9 vs 11.8 d; = 0.04). The early intubation cohort had a lower mortality rate than the late intubation cohort (6% vs 30%, < 0.001) without significantly different respiratory mechanics at the time of intubation. The late intubation cohort was noted to have higher dead space ratio (0.40 vs 0.52; = 0.03). On review of CT scans, the late intubation cohort also had more dilated peripheral segments on imaging (two segments vs five segments).
The question as to whether delaying intubation is beneficial or harmful for patients with coronavirus disease 2019-induced hypoxemic respiratory failure has yet to be answered. As our approaches to coronavirus disease 2019 continue to evolve, the decision of timing of intubation remains paramount. Although noninvasive ventilation may allow for delaying intubation, it is possible that there are downstream effects of delayed intubation that should be considered, including the potential for pulmonary vascular thrombosis and intussusceptive angiogenesis with delayed intubation.
确定2019冠状病毒病病程中较早插管与较晚插管的受试者之间结局和呼吸力学的差异。
回顾性队列研究。
西北纪念医院重症监护病房。
2020年3月至2020年6月期间因2019冠状病毒病插管的所有患者。
根据插管时间对患者进行分层：30名受试者在就诊后4 - 24小时插管，24名受试者在就诊后5 - 10天插管。提取并分析基线特征、住院情况、呼吸机力学参数和结局。人工复查10份临床可用的CT扫描，以确定肺血管血栓形成和套叠性血管生成的证据。
早期插管组和晚期插管组从症状出现到插管的中位时间有显著差异，晚期插管组在病程中插管较晚（7.9天对11.8天；P = 0.04）。早期插管组的死亡率低于晚期插管组（6%对30%，P < 0.001），插管时呼吸力学参数无显著差异。晚期插管组的死腔率较高（0.40对0.52；P = 0.03）。在CT扫描复查中，晚期插管组在影像学上外周段扩张也更多（2段对5段）。
对于2019冠状病毒病所致低氧性呼吸衰竭患者，延迟插管是有益还是有害的问题尚未得到解答。随着我们对2019冠状病毒病的治疗方法不断发展，插管时机的决策仍然至关重要。虽然无创通气可能允许延迟插管，但延迟插管可能存在的下游效应也应予以考虑，包括延迟插管导致肺血管血栓形成和套叠性血管生成的可能性。
