Optimal timing for intubation in patients on non-invasive ventilation: A retrospective cohort study

Background and AimsThe timing of transition from non-invasive ventilation (NIV) to invasive ventilation in the intensive care unit (ICU) is uncertain due to a lack of clinical evidence. This study aimed to identify the optimal timing of intubation in patients with respiratory failure managed with NIVs.MethodsA single-center observational study was conducted in Tokyo, Japan. Patients in the ICU managed with NIV between 2013 and 2022 were screened. The primary outcome was 28-day invasive ventilator-free days. Statistical analyses used locally estimated scatter plot smoothing (LOESS) and generalized linear mixed models to estimate the association between the timing of transition and prolonged intubation duration.ResultsDuring the study period, 139 of 589 adult ICU patients receiving NIV transitioned to invasive ventilation. The LOESS curve indicated the longest 28-day ventilator-free days around 24 h after NIV initiation, after which the primary outcome decreased linearly. Late intubation after 24 h of NIV initiation was associated with fewer 28-day ventilator-free days (adjusted mean difference: -0.22 days [95% confidence interval: -0.31, -0.13]).ConclusionWe identified a non-linear association between the timing of intubation and 28-day invasive ventilator-free days. The critical 24-h time window for patients on NIV was associated with longer 28-day invasive ventilator-free days. The timing of transition from non-invasive ventilation (NIV) to invasive ventilation in the ICU is uncertain.This study showed that the 28-day invasive ventilator-free days peaked around 24 h after the start of NIV for patients with respiratory failure who required tracheal intubation after using NIV.Patients using NIV should be closely monitored and evaluated within 24-h window to determine if tracheal intubation is necessary.