Team publishes research analyzing intubation data from across U.S.
Investigators from Delaware Clinical and Translational Research (DE-CTR) ACCEL Program institutions recently published their research findings on the highly disputed topic of when to intubate an adult COVID-19 patient.
“The optimal timing of intubation in patients with respiratory failure has been controversial for a long time. This controversy took on more urgency and became more heated during the pandemic. … We hoped that by looking at outcomes of COVID-19 patients from ‘real world data,’ we could contribute to understanding this question,” explained Michael T. Vest, DO, critical care physician at ChristianaCare Health System and Assistant Professor of Medicine at Sidney Kimmel Medical College at Thomas Jefferson University, who was the Principle Investigator (PI) on the research.
The paper, “Intubation timing in COVID-19 patients based on ROX index and association with patient outcomes,” was published online in Respiratory Care Journal in March.
During a previous ACCEL Junior Investigator Network (JIN) presentation, Dr. Vest discussed how the team used Cerner Real-World Data, which is a national, de-identified, person-centric data set solution, to analyze intubation timing among adult COVID-19 patients. He also expressed how this research benefitted from the use of ACCEL’s Biostatistics, Epidemiology, and Research Design (BERD) Core during the presentation. He said that while this project wasn’t funded through ACCEL, the BERD Core “allowed us to have statistical support and methodology guidance which were invaluable in completing this project.”
In addition, Dr. Vest and the team utilized database support from the ChristianaCare Institute for Research on Equity and Community Health (iREACH).
The research team and paper’s authors included:
- Michael T. Vest, DO, FCCP, FCCM, Critical Care Physician at ChristianaCare Health System; Assistant Professor, Medicine at Sidney Kimmel Medical College, Thomas Jefferson University
- Richard Caplan, PhD, Senior Biostatistician at ChristianaCare Health System iREACH
- Mitch Fawcett, MBA, Senior Systems Engineer at ChristianaCare Health System iREACH
- Andrew Deitchman, MD, Critical Care Medicine at ChristianaCare Health System
- Dominic Valentino III, DO, FCCP, FACOI, Pulmonology, Critical Care, and Sleep Medicine at ChristianaCare Health System
- Mithil J Gajera, MD, Critical Care Medicine at ChristianaCare Health System
- Claudine Jurkovitz, MD, MPH, Director of Clinical Research at ChristianaCare Health System iREACH; Lead Biostatistics, Epidemiology, and Research Design (BERD) Core with DE-CTR ACCEL Program; and Director of the Centralized Research Support Network (CRSN) with DE-INBRE
Higher ROX scores prior to intubation were positively associated with survival. Older age and increasing days from admission to intubation were associated with mortality.
Vest MT, Caplan R, Fawcett M, Deitchman A, Valentino D, Gajera M, Jurkovitz C. Intubation Timing in COVID-19 Patients Based on ROX Index and Association with Patient Outcomes. Respir Care. 2022 Mar 17:respcare.09937. doi: 10.4187/respcare.09937. Epub ahead of print. PMID: 35301244.
Dr. Vest said that some experts in critical care were making recommendations to intubate COVID-19 patients with respiratory failure “extremely early” in the course of treatment while others were choosing to intubate patients only as a “last resort.”
The research found, Dr. Vest said, that the higher the Respiratory Rate Oxygenation (ROX) scores – the ratio of oxygen saturation as measured by pulse oximetry divided by the fraction of inspired oxygen to respiratory rate – at time of intubation were associated with improved chances of patient survival.
“This means that relatively earlier intubation was not associated with harm and may have benefit, so we don’t need to hold intubation as only a treatment of last resort,” Dr. Vest said.
During the JIN presentation, Dr. Vest said, “This idea of avoiding intubation at all costs – which is very different than what we do in bacterial pneumonia or flu pneumonia – is probably not a good idea and that maybe this is suggesting we should treat [COVID-19] the same as we would patients with other causes of respiratory failure.”
However, Dr. Vest pointed out, “the application of this data remains a bit of an art: There is not any one data point that tells a physician that a patient will benefit or not benefit from intubation.”
While tools like ROX may help the clinician during treatment, any decision on when to intubate ultimately needs to be individualized for each patient.