Risk Factors and Outcomes Associated With Re-Intubation Secondary to Respiratory Failure in Patients With COVID-19 ARDS

Background: COVID-19 is associated with variable symptoms and clinical sequelae. Studies have examined the clinical course of these patients, finding a prolonged need for invasive ventilation and variable re-intubation rates. However, no research has investigated factors and outcomes related to re-intubation secondary to respiratory failure among patients with COVID-19 with ARDS. Methods: We conducted a single-center, retrospective study on subjects intubated for ARDS secondary to COVID-19. The primary outcome was re-intubation status; secondary outcomes were hospital and ICU stay and mortality. Data were analyzed using between-group comparisons using chi-square testing for categorical information and Student t test for quantitative data. Univariate and multivariate logistic regression was performed to determine factors related to re-intubation and mortality as dependent variables. Results: One hundred and fourteen subjects were included, of which 32% required re-intubation. No between-group differences were detected for most demographic variables or comorbidities. No differences were detected in COVID-19 treatments, noninvasive respiratory support, mechanical circulatory support, or duration of ventilation. Midazolam (odds ratio [OR] 5.55 [95% CI 1.83-16.80], P = .002), fentanyl (OR 3.64 [95% CI 1.26-10.52], P = .02), and APACHE II scores (OR 1.08 [95% CI 1.030-1.147], P = .005) were independently associated with re-intubation (area under the curve = 0.81). Re-intubated subjects had extended hospital (36.7 +/- 22.7 d vs 26.1 +/- 12.1 d, P = .01) and ICU (29.6 +/- 22.4 d vs 15.8 +/- 10.4 d, P < .001) stays. More subjects died who failed extubation (49% vs 3%, P < .001). Age (OR 1.07 [95% CI 1.02-1.23], P = .005), male sex (OR 4.9 [95% CI 1.08-22.35], P = .041), positive Confusion Assessment Method for the ICU (CAM-ICU) (OR 5.43 [95% CI 1.58-18.62], P = .007), and re-intubation (OR 12.75 [95% CI 2.80-57.10], P < .001) were independently associated with death (area under the curve = 0.93). Conclusions: Midazolam, fentanyl, and higher APACHE II scores were independently associated with re-intubation secondary to respiratory failure in subjects with COVID-19-related ARDS. Furthermore, age, male sex, positive CAM-ICU, and re-intubation were independently associated with mortality. Re-intubation also correlated with prolonged hospital and ICU stay.