Independent risk factors for reintubation in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 include a higher score on the Acute Physiology and Chronic Health Evaluation (APACHE) II at intensive care unit (ICU) admission and midazolam or fentanyl use within 48 hours before extubation. These were among study findings published in Respiratory Care.
Researchers conducted a single-center, retrospective study from March 2020 to February 2022 exploring factors and outcomes related to reintubation secondary to respiratory failure in patients who had ARDS secondary to COVID-19. The primary outcome was re-intubation secondary to respiratory failure, with respiratory failure defined as oxygen saturation (SpO2) less than 88% and increased work of breathing within 1 week of extubation.
All study participants met Berlin criteria for ARDS at intubation, were ventilated for at least 24 hours, passed a spontaneous breathing trial, and were electively extubated.
The cohort included 114 patients; 37 (32%) of those patients (mean [SD] age, 60.40 [14.80] years; 62% male; 62% Black; 22% Hispanic) required reintubation secondary to respiratory failure within 7 days. No differences were observed between patients needing vs not needing re-intubation with respect to sex (P =.30), race (P =.65), body mass index (P =.28), and dominant COVID-19 variant by time frame (alpha, beta, delta, omicron, P =.22). Likewise, use COVID-19 therapeutics were not significantly different between those who required reintubation and those who did not.
Our study demonstrated a re-intubation rate of 32%, which was higher than in heterogeneous ICU populations, and an association between positive CAM-ICU scores and increased mortality.
Patients who were reintubated had a similar initial duration of ventilation compared with those who were not reintubated (10.7 [6.7] days vs 10.3 [6.7] days, P = .74) but had an extended hospital length of stay (36.7 [22.7] days vs 26.1 [12.1] days, P =.01) and ICU length of stay (29.6 [22.4] days vs 15.8 [10.4] days, P <.001). Also, significantly more patients who failed extubation died (49% vs 3%, P <.001).
In multiple logistic regression analysis with reintubation as the dependent variable, APACHE II score (odds ratio [OR], 1.08; 95% CI, 1.03-1.15; P =.005), midazolam use (OR, 5.55; 95% CI, 1.83-16.8; P =.002), and fentanyl use (OR, 3.64; 95% CI, 1.26-10.52; P =.02) were independently associated with reintubation (model area under the curve=0.81).
In the final analysis model, age (OR, 1.07; 95% CI, 1.02-1.23; P =.005), male sex (OR, 4.90; 95% CI, 1.08-22.35; P =.041), positive Confusion Assessment Method for the ICU (CAM-ICU) scores (OR, 5.43; 95% CI, 1.58-18.62; P = .007), and reintubation (OR, 12.75; 95% CI, 2.80-57.10; P <.001) were independently associated with mortality (model area under the curve=0.93).
Study limitations include the retrospective, observational design from a single-center with a relatively small sample size. In addition, most of the participants were non-Hispanic Black or Hispanic, and data were obtained from electronic medical records. Furthermore, ventilator settings, laboratory values, or sedative and analgesic dosages used were not analyzed during the ICU stay.
“Our study demonstrated a re-intubation rate of 32%, which was higher than in heterogeneous ICU populations, and an association between positive CAM-ICU scores and increased mortality,” stated the study authors. “In addition, we found that re-intubation was independently associated with higher mortality rates and correlated with prolonged hospital and ICU stays.”