Early Versus Delayed Intubation of Patients With COVID-19

A common manifestation of COVID-19 is severe acute hypoxemic respiratory failure. Management
of acute hypoxemic respiratory failure associated with COVID-19 often includes mechanical
ventilation. The optimal timing of initiation of invasive mechanical ventilation remains
unknown.

On the one hand, early initiation of invasive mechanical ventilation (i.e. early endotracheal
intubation) has been advocated as a means to reduce subsequent possible aerosolization of the
virus, as would happen by alternate means of oxygenation/ventilation allowing air leaks.
Also, early intubation may prevent the induction of self-inflicted lung injury in patients
who breath spontaneously and have high respiratory drive and, therefore, large transpulmonary
pressure swings. On the other hand, delaying intubation, by trying alternate means of
oxygenation/ventilation, may mean that some of the patients may not be intubated at all and
therefore will be protected from the adverse events of invasive mechanical ventilation (such
as ventilator-induced lung injury, ventilator-associated pneumonia and ventilator-induced
diaphragmatic dysfunction). The latter strategy may also address the unavailability of enough
ventilators to meet the increased demand of treating patients with COVID-19.

Given that no randomized controlled trials are currently available to guide clinical practice
regarding optimal timing of intubation, we propose a single-center randomized controlled
feasibility trial to compare early intubation versus delayed intubation among patients with
COVID-19 suffering from severe acute hypoxemic respiratory failure. The aim is that we gain
experience and produce pilot data, which could inform the design of a subsequent large
multi-center clinical trial.