SUMMARY

OBJECTIVE:

The objective of this study was to assess the predictors of survival among patients with coronavirus disease 2019 who underwent tracheal intubation, as part of a hospital cohort study.

METHODS:

This retrospective cohort study in the Rio do Sul County Hospital, Santa Catarina, Brazil, from April 2020 to May 2021, focused on patients aged 18 years or older intubated for coronavirus disease 2019. We assessed the 90-day survival of intubated patients by estimating the hazard ratio using a Cox proportional hazards regression model.

RESULTS:

The study included 132 participants, with an average age of approximately 60 years. Tracheal intubation was successfully accomplished in 97% of cases within two attempts. The overall mortality rate was 62.9%. Notably, mortality rates were significantly higher in patients aged over 60 years (hazard ratio=2.57; 95%CI 1.54–4.29; p<0.001), those with blood oxygen saturation below 85% (hazard ratio=1.92; 95%CI 1.03–3.57; p=0.04), instances where tracheal intubation was carried out using a conventional laryngoscope (hazard ratio=2.59; 95%CI 1.22–5.48; p=0.013), and when performed by emergency physicians (hazard ratio=3.96; 95%CI 1.51–10.4; p=0.005).

CONCLUSION:

Our analysis unveiled that the risk of death in intubated coronavirus disease 2019 patients is four times higher when an emergency physician, as opposed to an anesthesiologist, leads the tracheal intubation team.

KEYWORDS
Airway management; COVID-19; Critical care; Intubation; Pneumonia; Respiratory distress syndrome

INTRODUCTION

During the 2020–2021 coronavirus disease 2019 (COVID-19) pandemic, the rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulted in severe respiratory disease. Many affected areas lacked essential resources and infrastructure, leading to increased patient mortality. The initial World Health Organization data revealed hospitalization rates of 10–15%, with 39% requiring intensive care and 23% needing tracheal intubation and mechanical ventilation¹1. Ahmad I, Jeyarajah J, Nair G, Ragbourne SC, Vowles B, Wong DJN, et al. A prospective, observational, cohort study of airway management of patients with COVID-19 by specialist tracheal intubation teams. Can J Anaesth. 2021;68(2):196-203. https://doi.org/10.1007/s12630-020-01804-3
https://doi.org/10.1007/s12630-020-01804... . Despite standard protocols, global mortality of patients on mechanical ventilation ranged from 30 to 80%²2. Brandão Neto RA, Marchini JF, Marino LO, Alencar JCG, Lazar Neto F, Ribeiro S, et al. Mortality and other outcomes of patients with coronavirus disease pneumonia admitted to the emergency department: a prospective observational Brazilian study. PLoS One. 2021;16(1):e0244532. https://doi.org/10.1371/journal.pone.0244532
https://doi.org/10.1371/journal.pone.024... ,³3. Ranzani OT, Bastos LSL, Gelli JGM, Marchesi JF, Baião F, Hamacher S, et al. Characterisation of the first 250,000 hospital admissions for COVID-19 in Brazil: a retrospective analysis of nationwide data. Lancet Respir Med. 2021;9(4):407-18. https://doi.org/10.1016/S2213-2600(20)30560-9
https://doi.org/10.1016/S2213-2600(20)30... .

Coronavirus disease 2019 patients who needed tracheal intubation were severely ill and at risk of cardiovascular collapse⁴4. Mosier JM. Physiologically difficult airway in critically ill patients: winning the race between haemoglobin desaturation and tracheal intubation. Br J Anaesth. 2020;125(1):e1-e4. https://doi.org/10.1016/j.bja.2019.12.001
https://doi.org/10.1016/j.bja.2019.12.00... . Tracheal intubation was often performed rapidly, without prior face mask ventilation to prevent contamination, leading to quick desaturation and worsened conditions. These challenges complicated COVID-19 patient tracheal intubation⁵5. Detoni PB, Azevedo MP, Moraes LA, Carraretto AR. The coronavirus and the anesthesiologist. In: Diego LAS, Tardelli MA, Nunes RR, editors. SBA COVID-19 collection (in Portuguese). Rio de Janeiro (RJ): Brazilian Society of Anesthesiology; 2021. p. 47-69.,⁶6. Brazilian Intensive Care Medicine Association (Associação de Medicina Intensiva Brasileira). Guidance on orotracheal intubation in patients with COVID-19 (in Portuguese). [cited on 2022 Jun 29]. 2020. Available from: https://www.amib.org.br/diretrizes/
https://www.amib.org.br/diretrizes/... .

Worldwide healthcare had to adapt protocols for dealing with COVID-19. Specialized tracheal intubation teams were formed, including the Catarina Intubation Team in the Regional Hospital of Rio do Sul County, Brazil, in March 2020. The goal of this hospital cohort study was to assess the predictors of survival among COVID-19 patients who underwent tracheal intubation.

METHODS

This single-center cohort study occurred at High Itajai River Valley Hospital in Rio do Sul County, Brazil. The Research Ethics Committee of the University for the Development of the High Itajai River Valley granted an exemption from the requirement for patient consent forms for this observational study, which relied on data from information systems. The study received approval on May 28, 2021, with final approval n. 4741418. Eligible participants were adults (≥18 years) with positive COVID-19 tests requiring tracheal intubation from April 2020 to May 2021, excluding COVID-negative patients and those transferred to other hospitals. Survival analysis extended to 90 days from the tracheal intubation date. Our intubation team comprised 17 volunteers, with shifts covering all days of the week, including anesthesiologists, intensivists, anesthesiology residents, and emergency physicians.

Airway management adhered to a COVID-19-specific tracheal intubation protocol, guided by national and international guidelines⁵5. Detoni PB, Azevedo MP, Moraes LA, Carraretto AR. The coronavirus and the anesthesiologist. In: Diego LAS, Tardelli MA, Nunes RR, editors. SBA COVID-19 collection (in Portuguese). Rio de Janeiro (RJ): Brazilian Society of Anesthesiology; 2021. p. 47-69.

6. Brazilian Intensive Care Medicine Association (Associação de Medicina Intensiva Brasileira). Guidance on orotracheal intubation in patients with COVID-19 (in Portuguese). [cited on 2022 Jun 29]. 2020. Available from: https://www.amib.org.br/diretrizes/
https://www.amib.org.br/diretrizes/... -⁷7. American Society of Anesthesiology. [cited on 2022 Jul 14]. 2020. Available from: https://www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-on-occupational-health/coronavirus
https://www.asahq.org/about-asa/governan... . All members underwent practical training in protocol implementation, airway management, and personal protective equipment use. The team followed institutional procedures, with a group established for debriefing and error correction. Both conventional laryngoscopes and videolaryngoscopes (McGRATH™ MAC—Aircraft Medical LTD., Edinburgh, UK) were employed for tracheal intubation using prepared kits with essential materials, medications, and personal protective equipment. These kits were strategically placed in hospital wards, the emergency department, and the intensive care unit (ICU) COVID-19 sector. Outcomes were documented in medical records and on a form completed by team members. Information on length of stay and survival was extracted from patients’ medical records.

To estimate hazard ratios (HR), Cox proportional hazard regression models were used for statistical analysis. In the initial phase, the model was applied to each category of explanatory factors, including demographic data (block 1), comorbidities (block 2), symptoms (block 3), and factors related to tracheal intubation (block 4). The model then adjusted each patient’s length of hospital stay based on the outcome (death or discharge) in relation to these factors. The predicted outcome provided an estimate of the risk of death in relation to the duration of hospitalization, accounting for each factor. A 5% significance level was set for two-tailed Wald tests, and statistically significant factors were incorporated into a final multiple regression model.

We scrutinized the statistically significant variables while considering sample adequacy and the statistical power provided for hypothesis testing. To calculate the required number of deaths, we used the formula suggested by Schoenfeld⁸8. Schoenfeld DA. Sample-size formula for the proportional-hazards regression model. Biometrics. 1983;39(2):499-503. PMID: 6354290, which considers the study’s specifics:

where, to achieve a power of 80% at a one-tailed significance level of 5% (z_β = 0.841 and z_1-α = 1.645), it becomes essential to determine the minimum number of observed deaths for each group of exposed individuals (Prop_E), unexposed individuals (Prop_NE), and log-natural scale regression coefficient (${\log }_e^2\Delta$).

Complementary analyses included sensitivity, specificity, and accuracy for difficult airway prediction vs. confirmation using chi-square testing (p<0.05).

RESULTS

A cohort of 132 participants with an average age of around 60 years was recruited for the study. The majority were male, and the predominant ethnicity was Caucasian. Prevalent comorbidities included systemic arterial hypertension, diabetes mellitus, obesity, and heart disease. Participants exhibited various symptoms, with cough, dyspnea, and fever being the most frequently reported (Table 1).

All 132 patients experienced respiratory failure requiring tracheal intubation. Successful intubation rates were 91.7% on the first attempt and 97% on the second attempt. Predictions of difficult airways were made in 14.4% and confirmed in 8.3%, with moderate sensitivity (55%) and high specificity (89%). The prediction’s accuracy was 86% (p=0.0004), highlighting its reliability in anticipating difficult airways. However, the study’s unfortunate high mortality rate was evident in the 90-day follow-up, with 83 deaths (62.9%) and 49 discharges indicating recovery (27.1%). For further insights, Table 2 details the factors associated with tracheal intubation.

In our analysis of adjusted Cox proportional hazards regression models, we observed a fourfold increase in the risk of death when tracheal intubation was performed by emergency physicians (HR=3.96, 95%CI 1.51–10.4; p=0.005), with similar findings for conventional laryngoscope use (HR=2.59, 95%CI 1.22–5.48; p=0.013), patient age over 60 years (HR=2.57, 95%CI 1.54–4.29; p<0.001), and severe hypoxemia (HR=1.92, 95%CI 1.03–3.57; p=0.04). These results maintain statistical power due to sufficient sample size (Table 3).

Discussion

In this context, our performance met expectations, showcasing a high success rate within one or two attempts for tracheal intubations. The research reveals a moderate sensitivity and noteworthy specificity, underscoring the substantial accuracy attainable through difficult airway prediction. The study emphasizes advanced age and severe hypoxemia as independent and cumulative mortality factors in COVID-19 patients. Moreover, our findings suggest reduced survival rates among patients intubated by emergency physicians.

The surge in COVID-19-related respiratory failure has strained global healthcare providers. Ensuring successful, efficient endotracheal intubation is crucial, with specialized teams offering better outcomes. Patient survival depends on factors such as age and pathology severity, while equipment and clinician skill also influence results. Intubation teams have demonstrated proficiency in COVID-19 patient intubations, achieving initial success rates between 85 and 92%, which increased from 97 to 98% upon the second attempt⁹9. Gandhi A, Sokhi J, Lockie C, Ward PA. Emergency tracheal intubation in patients with COVID-19: experience from a UK centre. Anesthesiol Res Pract. 2020;2020:8816729. https://doi.org/10.1155/2020/8816729
https://doi.org/10.1155/2020/8816729...

10. Jarvis N, Schiavo S, Bartoszko J, Ma M, Chin KJ, Parotto M. A specialized airway management team for COVID-19 patients: a retrospective study of the experience of two Canadian hospitals in Toronto. Can J Anaesth. 2022;69(3):333-42. https://doi.org/10.1007/s12630-021-02169-x
https://doi.org/10.1007/s12630-021-02169... -¹¹11. Magor K, Chhina T, Cacic I, Wong BI, Beheiry H. Performance and impact of an airway management team launched during the COVID-19 pandemic. Can J Anaesth. 2022;69(2):205-15. https://doi.org/10.1007/s12630-021-02144-6
https://doi.org/10.1007/s12630-021-02144... . In their study on COVID-19 patients, Zheng et al. reported intubation success rates using videolaryngoscopes ranging from 89 to 94% on the first attempt and 80 to 100% on the second attempt¹²12. Zheng H, Li S, Sun R, Yang H, Chi X, Chen M, et al. Clinical experience with emergency endotracheal intubation in COVID-19 patients in the intensive care units: a single-centered, retrospective, descriptive study. Am J Transl Res. 2020;12(10):6655-64. PMID: 33194062. Lower success rates were observed with conventional laryngoscope, at 70% on the first attempt and 83% on the second attempt¹²12. Zheng H, Li S, Sun R, Yang H, Chi X, Chen M, et al. Clinical experience with emergency endotracheal intubation in COVID-19 patients in the intensive care units: a single-centered, retrospective, descriptive study. Am J Transl Res. 2020;12(10):6655-64. PMID: 33194062. Conversely, Wong et al. observed no variation in intubation success rates on the first attempt between the two equipment types¹³13. Wong DJN, Boghdadly K, Owen R, Johnstone C, Neuman MD, Andruszkiewicz P, et al. Emergency airway management in patients with COVID-19: a prospective international multicenter cohort study. Anesthesiology. 2021;135(2):292-303. https://doi.org/10.1097/ALN.0000000000003791
https://doi.org/10.1097/ALN.000000000000... .

The American Society of Anesthesiologists’ guidelines advise conducting a pre-airway management risk assessment for difficult airway situations¹⁴14. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for management of the difficult airway. Anesthesiology. 2022;136(1):31-81. https://doi.org/10.1097/ALN.0000000000004002
https://doi.org/10.1097/ALN.000000000000... . In a meta-analysis of 50,760 patients, the prediction of a difficult airway demonstrated low to moderate sensitivity (20–62%) and moderate to high specificity (82–97)¹⁵15. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103(2):429-37. https://doi.org/10.1097/00000542-200508000-00027
https://doi.org/10.1097/00000542-2005080... . Similarly, Norskow et al. observed a notably higher specificity compared to sensitivity in difficult airway prediction¹⁶16. Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia. 2015;70(3):272-81. https://doi.org/10.1111/anae.12955
https://doi.org/10.1111/anae.12955... .

Several studies have consistently reported increased mortality among elderly COVID-19 patients with severe hypoxemia¹⁷17. Boscolo A, Pasin L, Sella N, Pretto C, Tocco M, Tamburini E, et al. Outcomes of COVID-19 patients intubated after failure of non-invasive ventilation: a multicenter observational study. Sci Rep. 2021;11(1):17730. https://doi.org/10.1038/s41598-021-96762-1
https://doi.org/10.1038/s41598-021-96762...

18. Cummings MJ, Baldwin MR, Abrams D, Jacobson SD, Meyer BJ, Balough EM, et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. Lancet. 2020;395(10239):1763-70. https://doi.org/10.1016/S0140-6736(20)31189-2
https://doi.org/10.1016/S0140-6736(20)31...

19. Ramírez-Plascencia LE, Vázquez-León AP, Villaseñor-Magaña A, Correa-Valdéz M, Carrillo-Ibarra S, Sifuentes-Franco S. Factors possibly associated with mortality in intubated COVID-19 patients: a retrospective study. Pathogens. 2022;11(2):235. https://doi.org/10.3390/pathogens11020235
https://doi.org/10.3390/pathogens1102023...

20. Mejía F, Medina C, Cornejo E, Morello E, Vásquez S, Alave J, et al. Oxygen saturation as a predictor of mortality in hospitalized adult patients with COVID-19 in a public hospital in Lima, Peru. PLoS One. 2020;15(12):e0244171. https://doi.org/10.1371/journal.pone.0244171
https://doi.org/10.1371/journal.pone.024... -²¹21. Zhu W, Zhang H, Li Y, Ding Z, Liu Z, Ruan Y, et al. Optimizing management to reduce the mortality of COVID-19: experience from a designated hospital for severely and critically Ill patients in China. Front Med (Lausanne). 2021;8:582764. https://doi.org/10.3389/fmed.2021.582764
https://doi.org/10.3389/fmed.2021.582764... . Increased mortality among older patients can be linked to age-associated immune responses, culminating in reduced effectiveness and heightened inflammation¹⁹19. Ramírez-Plascencia LE, Vázquez-León AP, Villaseñor-Magaña A, Correa-Valdéz M, Carrillo-Ibarra S, Sifuentes-Franco S. Factors possibly associated with mortality in intubated COVID-19 patients: a retrospective study. Pathogens. 2022;11(2):235. https://doi.org/10.3390/pathogens11020235
https://doi.org/10.3390/pathogens1102023... ,²¹21. Zhu W, Zhang H, Li Y, Ding Z, Liu Z, Ruan Y, et al. Optimizing management to reduce the mortality of COVID-19: experience from a designated hospital for severely and critically Ill patients in China. Front Med (Lausanne). 2021;8:582764. https://doi.org/10.3389/fmed.2021.582764
https://doi.org/10.3389/fmed.2021.582764... . Hypoxemia is intricately tied to an inflammatory response. Patients afflicted by severe hypoxemia in the context of COVID-19 exhibit elevated levels of proinflammatory cytokines, lung injury, and acute respiratory distress syndrome²⁰20. Mejía F, Medina C, Cornejo E, Morello E, Vásquez S, Alave J, et al. Oxygen saturation as a predictor of mortality in hospitalized adult patients with COVID-19 in a public hospital in Lima, Peru. PLoS One. 2020;15(12):e0244171. https://doi.org/10.1371/journal.pone.0244171
https://doi.org/10.1371/journal.pone.024... ,²¹21. Zhu W, Zhang H, Li Y, Ding Z, Liu Z, Ruan Y, et al. Optimizing management to reduce the mortality of COVID-19: experience from a designated hospital for severely and critically Ill patients in China. Front Med (Lausanne). 2021;8:582764. https://doi.org/10.3389/fmed.2021.582764
https://doi.org/10.3389/fmed.2021.582764... . Tang et al. observed higher mortality with intubations by emergency physicians compared with anesthesiologists²²22. Tang TH, Yang ML, Chan OY, Chan LP, Ho HF. Airway managed by emergency physicians or anaesthesiologists in trauma patients: a retrospective cohort analysis of outcomes. Hong Kong J Emerg Med. 2021;28(5):269-78. https://doi.org/10.1177/1024907920931719
https://doi.org/10.1177/1024907920931719... .

This study has notable limitations, including its observational nature, absence of a comparator group, and being conducted at a single center.

CONCLUSION

In our study, mortality was four times higher when tracheal intubation was conducted by emergency physicians compared with cases where an anesthesiologist served as the intubation team leader. This adjustment accounts for confounding factors, including intubation location, comorbidities, patient age, and disease severity.

Publication Dates

History