key: cord-0915087-8apmnr1u authors: D'Amore, Jason; Meigher, Stephen; Patterson, Elizabeth; Sanapala, Sowmya; Tarr, Michael; Leisman, Dan; Jones, Michael; Moskovitz, Joshua B; Offenbacher, Joseph; Sperling, Jeremy title: Intubation outcomes and practice trends during the initial New York SARS‐COV‐19 surge at an academic, level 1 trauma, urban emergency department date: 2021-11-24 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12563 sha: a43fe95681168e80cfd4c03419c9444a79391c79 doc_id: 915087 cord_uid: 8apmnr1u OBJECTIVES: The goal of this study was to describe outcomes and associated characteristics of patients who were intubated during the initial (3/2020‐4/2020) New York City surge of the severe acute respiratory syndrome coronavirus 2 (COVID‐19) pandemic, during which time we were confronted by an unknown and unprecedented respiratory distress syndrome with extremely high degrees of morbidity and mortality. Our secondary aim was to analyze our physician's rapidly evolving approaches to COVID‐19 airway management. METHODS: A retrospective cohort analysis of all patients intubated at two emergency departments (EDs) for COVID‐19 suspected respiratory failure. In addition, a survey was done to analyze clinician airway management trends and attitudes as they evolved during that period. RESULTS: Ninety‐five patients met inclusion criteria for the study. Primary outcomes looked at the spectrum of mortality outcomes ranging from died on arrival (DOA) to the ED, died in the ED (DED), died an inpatient (DIH), and survival to discharge. Overall mortalitywas 71.6% with an average age of 62.7 years. Female sex, as a demographic, was associated with higher rates of survival to discharge at 42.3% when compared to males at 23.2% (P < 0.001). Mean age was 70.8 years DOA, 65.6 years DED, 62.9 years DIH, and 60.0 years for survivors (P = 0.0037). Initial lactate levels were 8.15 mmol/L DED, 3.56 mmol/L DIH, and 2.61 mmol/L survivors (P < 0.0001). Initial creatinine levels were 3.38 mg/dL DED, 1.94 mg/dL DIH, and 1.77 mg/dL survivors (P = 0.0073). D‐dimer levels were 7520.5 ng/mL DED, 5932.4 ng/mL DIH, and 1133.9 ng/mL survivors (P = 0.0045). Physician survey respondents reported high levels (69%) of laryngeal edema and prolonged post intubation hypoxia (>50% of time) and >80% remained concerned for their safety. There was a dramatic shift from early (73% of time) to late intubation strategies (67% of time) or non‐invasive approaches (28% of time) as the first surge of the pandemic evolved. CONCLUSION: Our findings demonstrate that several demographic, clinical and laboratory parameters correlated with mortality in our cohort of patients intubated during the initial phase of the COVID‐19 pandemic. These included male sex, advanced age, high levels of initial lactic acidosis, elevated D‐dimer, and chronic kidney disease/acute kidney injury. In contrast, presenting respiratory characteristics were not correlated with mortality. In addition, our findings demonstrate that physician attitudes and strategies related to COVID‐19 airway management evolved significantly and rapidly over the initial phase of the pandemic. concerned for their safety. There was a dramatic shift from early (73% of time) to late intubation strategies (67% of time) or non-invasive approaches (28% of time) as the first surge of the pandemic evolved. Conclusion: Our findings demonstrate that several demographic, clinical and laboratory parameters correlated with mortality in our cohort of patients intubated during the initial phase of the COVID-19 pandemic. These included male sex, advanced age, high levels of initial lactic acidosis, elevated D-dimer, and chronic kidney disease/acute kidney injury. In contrast, presenting respiratory characteristics were not correlated with mortality. In addition, our findings demonstrate that physician attitudes and strategies related to COVID-19 airway management evolved significantly and rapidly over the initial phase of the pandemic. and non-invasive modalities, was recognized to be the most important aspect of COVID-19 management for an unprecedented number of patients initially presenting to the emergency department (ED). 3 Early in the NYC COVID-19 surge, similar to established practice throughout the world, endotracheal intubation via rapid sequence induction (RSI) or a modified RSI was considered to be the treatment of choice for patients presenting with hypoxic respiratory failure. 4, 5 Data has shown that over the course of this initial COVID-19 surge, the borough of the Bronx was disproportionately impacted by both patient volumes and high levels of presenting acuity. 6 Our department serves as one of the primary centers for providing emergency care to the Bronx, an area with the highest mortality and hospitalization rates related to the COVID-19 infection, as of April 2020. 7 This study aims to capture a unique moment in emergency medicine history where we found ourselves confronting an unknown and unprecedented respiratory illness with extremely high degrees of morbidity and mortality as well as a clear infectious danger to the staff with incomplete knowledge as to contagion or virulence. We strove to further describe clinical trends and patient outcomes in a cohort of COVID-19 ED patients undergoing early airway management for respiratory failure in two urban academic emergency departments (ED) during the height of the first COVID-19 surge in NYC. Pre-oxygenation was maximized before endotracheal intubation. Intubations took place in a closed-door or negative pressure room. All staff wore personal protective equipment (PPE) consisting of, at minimum, N95 mask, eye goggles, face shield, and fluid resistant gown/suit over work clothes. The use of an intubating box or intubating sheet was employed in some cases. Staff in the room during the procedure was restricted to the intubator (typically an emergency medicine resident), an emergency medicine attending (and as needed, a senior emergency medicine resident), a nurse, and a respiratory therapist. A retrospective cohort analysis of 95 patients intubated in two EDs for COVID-19 suspected of respiratory failure from March 2, 2020 to April 18, 2020. Patients who met study criteria and were analyzed for outcomes, demographics, presenting vital signs, initial imaging and laboratory studies, and interventions recorded. Our primary study aims and design sought to describe the association between pre-selected demographic, clinical, and laboratory findings as they related to mortality for this unique patient cohort. The study's patient population was determined by a predetermined series of inclusion and exclusion criteria. Inclusion criteria included all patients over the age of 18 that were intubated within the ED with "high suspicion of COVID-19 respiratory failure" were included in the study. Criteria to be considered "high suspicion for COVID-19 respiratory failure" was defined as any patient intubated for respiratory distress, respiratory failure, or cardiac arrest presentation with at least 1 of the following 8 clinical features: (1) known COVID-19-positive or known antecedent exposure to a patient with COVID-19, (2) cough, (3) fever, (4) shortness of breath/dyspnea, imaging and laboratory data. The data report was exported to a pass- Final patient disposition served as the study's primary outcome. The four clinical outcomes considered were as follows: • Dead on arrival (DOA):if the patient arrived in cardiac arrest with high suspicion of COVID-19 and was unable to be resuscitated. • Died in ED (DED): the patient did not survive ED resuscitation attempts. • Died as an inpatient/died in hospital (DIH). • Survived to hospital discharge. In addition to the aforementioned primary outcomes a series of patient characteristics were also considered in describing the patient cohort. Patient demographics included age, sex, height, and weight. Presenting initial vital signs and selected laboratory findings were likewise analyzed. Furthermore, underlying medical conditions including reactive airway disease (asthma/chronic obstructive pulmonary disease), hypertension, coronary artery disease, congestive heart failure, diabetes mellitus, and HIV were also considered. Our data analysis was conducted to specifically consider the impact of pre-identified demographic, clinical, and laboratory characteristics on primary patient outcomes of those included in the study. This was done via the following statistical analysis: Categorical variables are presented as means with SD. Continuous variables are presented as frequencies (%). An ANOVA analysis was used to compare outcomes across the primary outcome groups and data are presented with P values. A χ 2 was used for categorical values and the P-values are reported. The delta SpO 2 was defined as the difference between the first recorded hospital SpO 2 and the first post intubation Sp0 2 . It was initially hypothesized to potentially correlate with success of resuscitation and favorable outcomes. Based on our initial analysis, 3 respiratory factors considering initial hypoxemia (initial SpO 2 , delta SpO 2 , and initial respiratory rate) and 3 systemic indicators (initial creatinine, initial lactate, and initial D-dimer) were selected for comparison between patients who died in the ED versus those who survived the ED but died later in their hospital course. To compare the groups, we performed a one-way ANOVA with a Sidak post-hoc comparison. Data that violated the homoscedastic error assumption were natural logarithm (Ln)-transformed. To offset availability bias from complete-case analysis, we used mean imputation for missing data among the 6 variables of interest. To explore secular changes in hypoxemia severity at the time of intubation over the study period, we fitted a Loess regression on preintubation SpO 2 as a function of date. All analysis was performed in SAS University Edition (SAS Institute, Cary, NC). To assess physicians' evolving attitudes and perceptions concerning intubation for respiratory distress during the initial COVID-19 surge, a 10-question SurveyMonkey was administered to faculty and residents. The survey design included multiple choice and Likert responses that assessed the intubating experience, perceptions of staff safety, approach to non-invasive strategies, as well as the dynamic practice environment during the study period. The survey was sent to staff on May 13 and closed on June 1 and consisted of 10 discrete questions. Data are presented as simple response percentages and the survey instrument is available for review in Appendix 1. One-hundred-sixty-five (165) consecutive patients were identified as having been intubated during the designated study period, and 95 patients ultimately met study inclusion criteria. All 95 patients were successfully intubated in the ED with no need for surgical airway inter-vention or the use of adjunct rescue devices. All patients were followed through 1 of the 4 primary outcomes including 4 DOA (4%), 12 DED (12.6%), 52 DIH (55%), and 27 patients survived to discharge (28.5%). All patients had reached a final disposition by 120 days. Primary study aims looked to assess patient outcomes from this unique patient cohort related to underlying demographic characteristics including age and sex. Overall mortality among the cohort was found to be 71.6%. A total of 72.6% of included patients were male. Of the 26 women who met criteria for inclusion, 11 In addition to respiratory findings, hemodynamic parameters were also initially considered for their possible association with patient outcomes. This included the prevalence of mild tachycardia, with an average heart rate of 108 beats per minute, without hypotension. The Although underlying demographic and exam characteristics were found to contribute to patient outcome following ED intubation, Because of the complex nature and continuously evolving understanding of this unprecedented disease process, long-term morbidity was thought to exceed the parameters of the study, and primary outcomes focused on mortality to assess for primary patient outcomes. Furthermore, decisions as to out-of-hospital clinical protocols and assessment of mortality exceeded the parameters of this study, and as such, all patients presenting to the ED were included regardless of the outcomes of initial resuscitation efforts. The physician survey was conducted ≈6 weeks after the COVID-19 surge. Although timely, factors such as recall biases and the over or under emphasized what the physicians remember experiencing during this highly stressful pandemic period. Furthermore, the survey tool itself was not previously validated, and as such, subjectivity and aforementioned biasing factors could have impacted findings. This study describes a unique moment in emergency medicine his- Abbreviations: RR, respiratory rate; RAAS, A class of blood pressure medication Renin-Angtiotensin-Aldosterone System. Abbreviations: CI, confidence interval; ED, emergency department; Ln, natural logarithm; SpO 2 , oxygen saturation measured by pulse oximetry. Displays the mean initial value of each indicator in patients who died in the ED versus who died in hospital, as well as the mean difference between groups with 95% CI from the Sidak post-hoc comparison. The P-value column displays to the P-value corresponding the post-hoc comparison whereas the P ANOVA column displays the P-value corresponding to the F statistic for the overall ANOVA. a Delta SpO 2 defined as the first SpO 2 after introduction of supplemental oxygen minus the initial room air SpO 2 . b Displays the back-transformed values from the Ln-transformed D-dimer analysis for purposes of interpretation. Box-and-whisker plots for initial pulmonary and systemic indicators at ED arrival for patients who died in the ED versus died in hospital versus survived to discharge. Boxes indicate 25th to 75th percentile, whiskers represent minimum and maximum values. Horizontal bar indicates group median. "+" indicates group mean. The P-value from the Sidak post-hoc comparison of patients who died in the ED versus those who died in hospital is displayed over the bracket. Because D-dimer displayed a beta distribution that violated the homoscedastic error assumption, the natural logarithm transformed values were used for analysis COVID-19 patients evolved drastically. In the first few weeks, the department approach was to intubate patients early in their ED stay and avoid high flow nasal cannula and noninvasive ventilation out of fear of viral aerosolization and infecting staff. Whether this fear was justified is an area of debate. 10 Patients were also intubated early given the levels of hypoxia noted in these COVID-19 patients despite some of these patients having clinical pictures that looked better than their pulse oximetry readings. This was the approach our colleagues in other NYC EDs were taking early in the NYC surge as well. Several weeks into this COVID-19 surge, it became clear that patients after intubation were spending weeks on mechanical ventilation with high mortality rates. 11 In early April, our department started applying alternative treatment methods to avoid intubation, such as placing patients in a prone position to improve oxygenation and the use of high flow nasal cannula and/or noninvasive ventilations. 12, 13, 14 This helped avoid a number of intubations. As a department, we accepted a larger degree of hypoxia while these other strategies were implemented, thus setting a stricter threshold for proceeding to intubation. We know of no other clinical entity that has resulted in such a dras- Our study cohort presented with advanced COVID-19 respiratory failure, uniformly in extremis and with an overall mortality of 71.6%. A total of 16.6% of our patient population did not even survive their resuscitation attempts in the ED, with 4% DOA and an additional 12.6% dying after intubation and during ED resuscitation. We found that within this cohort, male sex, advanced age, a history of coronary artery disease, the non-respiratory findings of lactic acidosis, elevated D-dimer, and CKD/AKI were correlated with death either in the ED or during the patient's hospital course. Fever, hypotension, and even initial respiratory status (including our analysis of the pre and post Sp0 2 [the Sp0 2 delta]) were not strongly correlated with outcomes (likely because of the fact that all patients were severely hypoxic on arrival). Increased BMI did not correlate with mortality. Although the explanation for this finding exceeded the scope of our study, it was hypothesized to be to the unique nature of the study cohort including patients of advanced age from nursing homes who are often cachectic at baseline because of underlying chronic medical conditions. We thought, based on changes in patient selection for intubation, that there would be a change in mortality for patients that were intubated over the study time period. One hypothesis was that the mortality might go up because patients who were more likely to survive would not be intubated at all. Unfortunately, the number of cases is too small to show a definite trend. Data on patients treated with non-invasive ventilatory strategies was out of the scope of this study. This study describes all COVID-19 intubations in 2 urban-academic ED during the NYC March/April surge that was early in the US pandemic. In our cohort of intubated COVID-19 patients, male sex, advanced age, and certain laboratory tests (lactic acidosis, elevated Ddimer, and CKD/AKI) were correlated with death either in the ED or during the patient's hospital course. Physician airway management strategies evolved rapidly during the course of this surge; however, the possible impact of those changes on patient outcomes exceeds the scope of our study. Additional research should evaluate the best strategies for RSI intubation of COVID-19 patients to avoid periods of post-intubation hypoxia as well as evaluate the best management of acute respiratory failure and hypoxia including timing of noninvasive strategies versus intubation. The authors declare no conflicts of interest. 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