Scant Science

Reflecting on the early pandemic period, some experts advocated for immediate intubation of patients showing rapid respiratory decline rather than delaying intervention. This debate centers on comparing early intubation with less invasive respiratory support techniques, such as non-invasive ventilation or supplemental oxygen via nasal tubes.

In critical situations, it is often challenging to adopt a wait-and-see approach, as this may lead to fatalities. Thus, the medical community typically favors progressing from the least to the most invasive interventions. Due to concerns stemming from the previous SARS outbreak, some specialists believed that early intubation would be more effective, leading to recommendations for this approach in March 2020, although such practices were quickly revised.

The prevailing assertions claim that "early" intubation resulted in numerous deaths, suggesting that individuals who did not require this invasive procedure were subjected to it based solely on speculation from medical practitioners. Intubation carries inherent risks, as one might expect from any invasive medical intervention.

Given the significance of this issue for the healthcare sector, one would anticipate a wealth of research. Ideally, we would see comprehensive, population-based studies that assess the consequences of early versus delayed intubation, as well as rigorous randomized controlled trials (RCTs) that clarify whether this approach was beneficial or detrimental.

Regrettably, similar to many aspects of COVID-19 research, the body of evidence surrounding early intubation remains surprisingly limited.

Observational Research

The primary studies available are observational in nature, comparing patients who underwent early intubation with those who delayed this intervention or assessing outcomes in hospitals that adopted versus abandoned early intubation policies.

A systematic review from 2021 provided a thorough summary of these studies, which collectively indicated little to no difference in mortality risk between early and late intubated patients. Additionally, attempts to employ alternative respiratory support methods for critically ill individuals showed no significant impact on outcomes.

While this evidence is far from conclusive, some studies have reported notable benefits from early mechanical ventilation. For instance, a study in India suggested that patients intubated within 48 hours of ICU admission had a lower mortality rate than those who waited longer. However, the inherent differences between these patient groups complicate the interpretation of results.

To truly address this question, randomized trials comparing non-invasive methods with conventional oxygen management are essential.

Randomized Evidence

The RECOVERY-RS trial evaluated three treatment options—continuous positive airway pressure (CPAP), high-flow nasal oxygen (HFNO), and standard oxygen therapy—in patients suffering from acute respiratory failure due to COVID-19. Randomization involved 1,273 participants, revealing no significant mortality differences between the CPAP and conventional treatment groups, nor between HFNO and standard therapy. Notably, CPAP reduced the number of patients requiring ventilation by 30% and delayed intubation by approximately one day.

This robust study exemplifies the type of large-scale randomized trial necessary for drawing reliable conclusions. While it concluded early due to a decrease in COVID-19 cases, it still provides valuable insights.

Although not strictly a study on "early" ventilation, it offers crucial information regarding the impact of less invasive methods on severe COVID-19 cases. The results indicate that these approaches reduce the likelihood of progressing to ventilation but have minimal effects on mortality rates. Adverse events occurred more frequently in the CPAP and HFNO groups compared to traditional treatment.

Another smaller randomized trial from Colombia that assessed HFNO against standard management yielded similar findings. While less invasive techniques may have some advantages for individuals with severe respiratory distress caused by COVID-19, the effects are modest and difficult to quantify.

Bottom Line: Uncertainty

The current evidence suggests that early intubation likely had a limited impact on patient outcomes. Patients receiving non-invasive treatments, such as CPAP, were somewhat less likely to require mechanical ventilation compared to those given traditional care, resulting in reduced ventilator usage without a corresponding decrease in mortality. This finding does not hold true for all less invasive techniques like HFNO.

It is probable that some patients were unnecessarily intubated, which may have caused harm, yet quantifying this harm is challenging. There may also be a potential benefit, particularly for patients with severe organ damage upon ICU admission.

In summary, we could have improved our response in March 2020 during an unprecedented medical crisis. Nevertheless, the notion that ventilators were primarily responsible for widespread fatalities among COVID-19 patients is unfounded.

The precise consequences of early pandemic interventions remain uncertain. It is plausible that early intubation policies contributed to some deaths while also saving others. Some studies suggest benefits for certain patients, while others indicate potential harm. The brevity of the early intervention period—just 2-3 months—leaves us with limited information to guide future decisions. By early April 2020, for instance, the UK NHS advised trialing CPAP or similar methods before intubation, a protocol many had already experienced.

Even subsequent randomized trials largely ceased after the early intubation approach fell out of favor, leaving us with numerous questions and few definitive answers.

Thanks to Dr. Avi Bitterman for input into this piece