Extubation Failure in Critically Ill COVID-19 Patients: Risk Factors and Impact on In-Hospital Mortality

Filip Ionescu, Markie S Zimmer, Ioana Petrescu, Edward Castillo, Paul Bozyk, Amr Abbas, Lauren Abplanalp, Sanjay Dogra, Girish B Nair, Filip Ionescu, Markie S Zimmer, Ioana Petrescu, Edward Castillo, Paul Bozyk, Amr Abbas, Lauren Abplanalp, Sanjay Dogra, Girish B Nair

Abstract

Purpose: We sought to identify clinical factors that predict extubation failure (reintubation) and its prognostic implications in critically ill COVID-19 patients.

Materials and methods: Retrospective, multi-center cohort study of hospitalized COVID-19 patients. Multivariate competing risk models were employed to explore the rate of reintubation and its determining factors.

Results: Two hundred eighty-one extubated patients were included (mean age, 61.0 years [±13.9]; 54.8% male). Reintubation occurred in 93 (33.1%). In multivariate analysis accounting for death, reintubation risk increased with age (hazard ratio [HR] 1.04 per 1-year increase, 95% confidence interval [CI] 1.02 -1.06), vasopressors (HR 1.84, 95% CI 1.04-3.60), renal replacement (HR 2.01, 95% CI 1.22-3.29), maximum PEEP (HR 1.07 per 1-unit increase, 95% CI 1.02 -1.12), paralytics (HR 1.48, 95% CI 1.08-2.25) and requiring more than nasal cannula immediately post-extubation (HR 2.19, 95% CI 1.37-3.50). Reintubation was associated with higher mortality (36.6% vs 2.1%; P < 0.0001) and risk of inpatient death after adjusting for multiple factors (HR 23.2, 95% CI 6.45-83.33). Prone ventilation, corticosteroids, anticoagulation, remdesivir and tocilizumab did not impact the risk of reintubation or death.

Conclusions: Up to 1 in 3 critically ill COVID-19 patients required reintubation. Older age, paralytics, high PEEP, need for greater respiratory support following extubation and non-pulmonary organ failure predicted reintubation. Extubation failure strongly predicted adverse outcomes.

Keywords: COVID-19; critical illness; novel coronavirus; reintubation.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: G.B. Nair has consulted for Genentech and Boehringer Ingelheim. All other authors have nothing to disclose.

Figures

Figure 1.
Figure 1.
Study population.
Figure 2.
Figure 2.
Cumulative incidence function plotting reintubation as event of interest and accounting for death of any cause as competing event.
Figure 3.
Figure 3.
Kaplan-Meier curve plotting survival of extubated COVID-19 patients who were reintubated and those who were not.

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