Halaseh Ramez M, Drescher Gail S, Al-Ahmad Ma'amoon, Masri Ihab H, Alayon Amaris L, Ghawanmeh Malik, Arar Tareq, Mohammad Saad Al-Deen, Pavate Rea, Bakri Mouaz Haj, Al-Tarbsheh Ali, AlGhadir-AlKhalaileh Mu'ed
Pulmonary and Critical Care Department, Cleveland Clinic Florida, Weston, Florida.
Respiratory Therapy Department, MedStar Washington Hospital Center, Washington, District of Columbia.
Respir Care. 2023 Dec 28;69(1):50-60. doi: 10.4187/respcare.10881.
COVID-19 is associated with variable symptoms and clinical sequelae. Studies have examined the clinical course of these patients, finding a prolonged need for invasive ventilation and variable re-intubation rates. However, no research has investigated factors and outcomes related to re-intubation secondary to respiratory failure among patients with COVID-19 with ARDS.
We conducted a single-center, retrospective study on subjects intubated for ARDS secondary to COVID-19. The primary outcome was re-intubation status; secondary outcomes were hospital and ICU stay and mortality. Data were analyzed using between-group comparisons using chi-square testing for categorical information and Student test for quantitative data. Univariate and multivariate logistic regression was performed to determine factors related to re-intubation and mortality as dependent variables.
One hundred and fourteen subjects were included, of which 32% required re-intubation. No between-group differences were detected for most demographic variables or comorbidities. No differences were detected in COVID-19 treatments, noninvasive respiratory support, mechanical circulatory support, or duration of ventilation. Midazolam (odds ratio [OR] 5.55 [95% CI 1.83-16.80], = .002), fentanyl (OR 3.64 [95% CI 1.26-10.52], = .02), and APACHE II scores (OR 1.08 [95% CI 1.030-1.147], = .005) were independently associated with re-intubation (area under the curve = 0.81). Re-intubated subjects had extended hospital (36.7 ± 22.7 d vs 26.1 ± 12.1 d, = .01) and ICU (29.6 ± 22.4 d vs 15.8 ± 10.4 d, < .001) stays. More subjects died who failed extubation (49% vs 3%, < .001). Age (OR 1.07 [95% CI 1.02-1.23], = .005), male sex (OR 4.9 [95% CI 1.08-22.35], = .041), positive Confusion Assessment Method for the ICU (CAM-ICU) (OR 5.43 [95% CI 1.58-18.62], = .007), and re-intubation (OR 12.75 [95% CI 2.80-57.10], < .001) were independently associated with death (area under the curve = 0.93).
Midazolam, fentanyl, and higher APACHE II scores were independently associated with re-intubation secondary to respiratory failure in subjects with COVID-19-related ARDS. Furthermore, age, male sex, positive CAM-ICU, and re-intubation were independently associated with mortality. Re-intubation also correlated with prolonged hospital and ICU stay.
新型冠状病毒肺炎（COVID-19）与多种症状及临床后遗症相关。已有研究对这些患者的临床病程进行了考察，发现其对有创通气的需求时间延长，再次插管率各异。然而，尚无研究调查过COVID-19合并急性呼吸窘迫综合征（ARDS）患者因呼吸衰竭导致再次插管的相关因素及结局。
我们对因COVID-19继发ARDS而插管的患者进行了一项单中心回顾性研究。主要结局为再次插管情况；次要结局为住院时间、重症监护病房（ICU）停留时间及死亡率。对分类信息采用卡方检验、对定量数据采用学生t检验进行组间比较分析数据。以再次插管和死亡率作为因变量进行单因素及多因素逻辑回归分析以确定相关因素。
共纳入114例患者，其中32%需要再次插管。大多数人口统计学变量或合并症在组间未检测到差异。在COVID-19治疗、无创呼吸支持、机械循环支持或通气持续时间方面未检测到差异。咪达唑仑（比值比[OR]5.55[95%置信区间1.83 - 16.80]，P = 0.002）、芬太尼（OR 3.64[95%置信区间1.26 - 10.52]，P = 0.02）及急性生理与慢性健康状况评分系统II（APACHE II）评分（OR 1.08[95%置信区间1.030 - 1.147]，P = 0.005）与再次插管独立相关（曲线下面积 = 0.81）。再次插管的患者住院时间延长（36.7±22.7天 vs 26.1±12.1天，P = 0.01），ICU停留时间延长（29.6±22.4天 vs 15.8±10.4天，P < 0.001）。拔管失败的患者死亡更多（49% vs 3%，P < 0.001）。年龄（OR 1.07[95%置信区间1.02 - 1.23]，P = 0.005）、男性（OR 4.9[95%置信区间1.08 - 22.35]，P = 0.041）、ICU意识模糊评估方法阳性（CAM-ICU）（OR 5.43[95%置信区间1.58 - 18.62]，P = 0.007）及再次插管（OR 12.75[95%置信区间2.80 - 57.10]，P < 0.001）与死亡独立相关（曲线下面积 = 0.93）。
咪达唑仑、芬太尼及较高的APACHE II评分与COVID-19相关ARDS患者因呼吸衰竭导致的再次插管独立相关。此外，年龄、男性、CAM-ICU阳性及再次插管与死亡率独立相关。再次插管还与住院时间和ICU停留时间延长相关。
