Review Article

Early versus delayed intubation and technique in COVID-19


Background: Novel coronavirus 2019 is the cause of the 2020 pandemic that was announced by the world health organization in March 2020. Coronavirus attacks the respiratory system and causes mild to severe hypoxemia. Therefore, a fraction of COVID-19 patients may need intubation and mechanical ventilation.
Methods: We performed a narrative review via searching in articles that were published in PubMed, Google Scholar, Scopus, web of scenic, Cochrane library, and Embase that mentioned to time of intubation COVID-19 patients and intubation techniques, manual searching was also completed. All the selected reviews and studies were limited to humans and the English language.
Results: First data from China mention that 5% of patients requiring intubation and mechanical ventilation (MV), there has been substantial debate about the time of intubation to patients with acute respiratory failure and intubation technique. At first, the specialists recommended early intubation. Although we are more familiar with the pathophysiology of coronavirus, the drawbacks versus the benefits of early intubation are still controversial. In addition, the intubation process itself is an aerosol-generating procedure and a high risk for patients and health care providers. In this review, we aim to review the previous studies and guidelines recommendations related to the time of intubation and intubation technique for COVID-19 patients.
Conclusion: Some previous studies suggested early tracheal intubation in severe COVID-19 patients may have the priority, while other studies advocate late intubation due to poor outcomes of intubation and weaning difficulties. However, intubation timing should be based on personalized medicine and case by case decision making to keep the best care and benefit of patients. And relying only on theoretical justification may have not good consequences.

[1] Shereen MA, Khan S, Kazmi A, Bashir N, Siddique R. COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses. J Adv Res. 2020; 24:91–8.
[2] Mohammadi M, Hadian M R, Varpaei H A. Exercise in COVID-19: Intensity and Timing. Asian J Sports Med.12(3):e113266.
[3] Brosnahan SB, Jonkman AH, Kugler MC, Munger JS, Kaufman DA. Covid-19 and respiratory system disorders current knowledge, future clinical and translational research questions. Arterioscler Thromb Vasc Biol. 2020; 40(11):2586-2597.
[4] Privitera D, Angaroni L, Capsoni N, Forni E, Pierotti F, Vincenti F, et al. Flowchart for non-invasive ventilation support in COVID-19 patients from a northern Italy Emergency Department. Intern Emerg Med. 2020; 15(5):767-771.
[5] Mohammadi M, Khafaee Pour Khamseh A, Varpaei H A. Invasive Airway "Intubation" in COVID-19 Patients; Statistics, Causes, and Recommendations: A Review Article. Anesth Pain Med. 2021;11(3):e115868.
[6] Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020;8(5):475–81.
[7] Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med. 2020; 46(6):1099–102.
[8] Tobin MJ, Laghi F, Jubran A. Caution about early intubation and mechanical ventilation in COVID-19. Ann Intensive Care. 2020;10(1):78.
[9] Diurno F, Numis FG, Porta G, Cirillo F, Maddaluno S, Ragozzino A, et al. Eculizumab treatment in patients with COVID-19: preliminary results from real life ASL Napoli 2 Nord experience. Eur Rev Med Pharmacol Sci. 2020; 24(7):4040–7.
[10] Piva S, Filippini M, Turla F, Catteneo S, Margola A, De Fulviis S, et al. Clinical presentation and initial management critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in Brescia, Italy. J Crit Care. 2020; 58:29-33.
[11] Cabrini L, Ghislanzoni L, Severgnini P, Landoni G, Baiardo Redaelli M, Franchi F, et al. Early versus late tracheal intubation in COVID-19 patients: a pro-con debate also considering heart-lung interactions. Minerva Cardiol Angiol. 2021; 69(5):596-605.
[12] Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. JAMA. 2020; 323(22): 2329–30.
[13] Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetist. Anaesthesia. 2020;75(6):785–99.
[14] Zuo M, Huang Y, Ma W, Xue Z, Zhang J, Gong Y, et al. Expert Recommendations for Tracheal Intubation in Critically III Patients with Noval Coronavirus Disease 2019. Chinese Med Sci J. 2020;35(2):105–9.
[15] Brewster DJ, Chrimes NC, Do TBT, Fraser K, Groombridge CJ, Higgs A, et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. Med J Aust. 2020;212(10):472–81.
[16] Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020;46(5):854-887.
[17] Kluge S, Janssens U, Welte T, Weber-Carstens S, Marx G, Karagiannidis C. German recommendations for critically ill patients with COVID‑19. Med Klin Intensivmed Notfmed. 2020 Dec;115(Suppl 3):111-114.
[18] Ferrando C, Colomina MJ, Errando CL, Llau JV. Anesthesiology and the Anesthesiologists at COVID-19. Rev Esp Anestesiol Reanim (Engl Ed). 2020; 67(6):289-291.
[19] Yao W, Wang T, Jiang B, Gao F, Wang L, Zheng H, et al. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations. Br J Anaesth. 2020; 125(1):e28-e37.
[20] Boscolo A, Pasin L. Outcomes of COVID-19 Patients Intubated After Failure of Non-Invasive Ventilation: A Multicenter Observational Study. Sci Rep. 2021; 11(1):17730.
[21] Daniel P, Mecklenburg M, Massiah C, Joseph MA, Wilson C, Parmar P, et al. Non-invasive positive pressure ventilation versus endotracheal intubation in treatment of COVID-19 patients requiring ventilatory support. Am J Emerg Med. 2021; 43:103–8.
[22] Papoutsi E, Giannakoulis VG, Xourgia E, Routsi C, Kotanidou A, Siempos II. Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: a systematic review and meta-analysis of non-randomized cohort studies. Crit Care. 2021; 25(1):121.
[23] Pierce A, Payette C, DelPrete B, Woo W, Benjenk I, Chintalapani S, et al. Staving Off Intubation: Characteristics of Outcomes in Early Versus Delayed Intubation in COVID-19. Crit Care Med. 2021; 49(1):62–62.
[24] Pandya A, Kaur NA, Sacher D, O'Corragain O, Salerno D, Desai P, et al. Ventilatory Mechanics in Early vs Late Intubation in a Cohort of Coronavirus Disease 2019 Patients With ARDS: A Single Center's Experience. Chest. 2021; 159(2):653-656.
[25] Siempos II, Xourgia E, Ntaidou TK, Zervakis D, Magira EE, Kotanidou A, et al. Effect of Early vs. Delayed or No Intubation on Clinical Outcomes of Patients With COVID-19: An Observational Study. Front Med. 2020; 7:614152.
[26] Matta A, Chaudhary S, Bryan Lo K, DeJoy R 3rd, Gul F, Torres R, et al. Timing of Intubation and Its Implications on Outcomes in Critically Ill Patients With Coronavirus Disease 2019 Infection. Crit Care Explor. 2020; 2(10):e0262..
[27] Phua J, Weng L, Ling L, Egi M, Lim C-M, Divatia JV, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med. 2020; 8(5):506-517.
[28] Kangelaris KN, Ware LB, Wang CY, Janz DR, Zhuo H, Matthay MA, et al. Timing of Intubation and Clinical Outcomes in Adults With Acute Respiratory Distress Syndrome. Crit Care Med. 2016; 44(1):120-9.
[29] Mosier JM, Sakles JC, Whitmore SP, Hypes CD, Hallett DK, Hawbaker KE, et al. Failed noninvasive positive-pressure ventilation is associated with an increased risk of intubation-related complications. Ann Intensive Care. 2015; 5(1):1–9.
[30] Siempos I, Xourgia E. Effect of early versus delayed or no intubation on clinical outcomes of patients with COVID-19. Front Med (Lausanne). 2020; 7: 614152.
[31] Meng L, Qiu H, Wan L, Ai Y, Xue Z, Guo Q, et al. Intubation and ventilation amid the COVID-19 outbreak: Wuhan’s experience. Anesthesiology. 2020;132(6):1317–32.
[32] El‐Boghdadly K, Wong DJN, Owen R, Neuman MD, Pocock S, Carlisle JB, et al. Risks to healthcare workers following tracheal intubation of patients with COVID‐19: a prospective international multicentre cohort study. Anaesthesia. 2020; 75(11):1437-1447.
[33] Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. Jama. 2020; 323(20):2052-2059.
[34] Wang Y, Lu X, Li Y, Chen H, Chen T, Su N, et al. Clinical course and outcomes of 344 intensive care patients with COVID-19. Am J Respir Crit Care Med. 2020;201(11):1430–4.
[35] Wang J, Hajizadeh N, Moore EE, McIntyre RC, Moore PK, Veress LA, et al. Tissue plasminogen activator (tPA) treatment for COVID-19 associated acute respiratory distress syndrome (ARDS): A case series. J Thromb Haem ost. 2020;18(7):1752–5.
[36] Ling L, Joynt GM, Lipman J, Constantin JM, Joannes-Boyau O. COVID-19: A critical care perspective informed by lessons learnt from other viral epidemics. Anaesth Crit Care Pain Med. 2020; 39(2):163–6.
[37] Bevilacqua S, Bottari V, Galeotti I. Systematic Application of Rapid Sequence Intubation With Remifentanil During COVID-19 Pandemic. Semin Cardiothorac Vasc Anesth. 2021; 25(1): 74–5.
[38] Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012; 27(4):417.e9-417.e13.
[39] Chahar P, Dugar S, Marciniak D. Airway management considerations in patients with COVID-19. Cleve Clin J Med. 2020;87(5):1–4.
[40] Kapoor D, Atter P, Kang A, Singh M. Emerging Perspectives of Endotracheal Intubation in Patients with Severe COVID- 19 Pneumonia: A Narrative Review. Arch Anesth Crit Care. 2021; 7(Spring):96–102.
[41] Sullivan EH, Gibson LE, Berra L, Chang MG, Bittner EA. In-hospital airway management of COVID- 19 patients. 2020; 24(1):292.
[42] Frat J-P, Ricard J-D, Quenot J-P, Pichon N, Demoule A, Forel J-M, et al. Non-invasive ventilation versus high-flow nasal cannula oxygen therapy with apnoeic oxygenation for preoxygenation before intubation of patients with acute hypoxaemic respiratory failure: a randomised, multicentre, open-label trial. Lancet Respir Med. 2019;7(4):303–12.
[43] Wong P, Lim WY. Aligning difficult airway guidelines with the anesthetic COVID-19 guidelines to develop a COVID-19 difficult airway strategy: a narrative review. J Anesth. 2020; 1–20.
[44] Hawkins A, Stapleton S, Rodriguez G, Mauricio Gonzalez R, Baker WE. Emergency tracheal intubation in patients with covid-19: A single-center, retrospective cohort study. West J Emerg Med. 2021;22(3):678–86.
[45] Cook TM, McGuire B, Mushambi M, Misra U, Carey C, Lucas N, et al. Airway management guidance for the endemic phase of COVID-19. Anaesthesia. 2021;76(2):251–60.
[46] Singh V, Sasidharan S, Nasser A, Dhillon H. Intubation and invasive Mechanical ventilation of COVID-19 Acute Respiratory Distress Syndrome patients. MRIMS J Heal Sci. 2021; 9(1):21.
[47] Lee CP, Yip YY, Chan AK, Ko CP, Joynt GM. Early intubation versus late intubation for COVID-19 patients: An in situ simulation identifying factors affecting performance and infection control in airway management. Anaesth Intensive Care. 2021; 49(4):284-291.
[48] Tsolaki V, Zakynthinos GE. Timing of Intubation in Covid-19 ARDS: What “time” really matters?. Crit Care. 2021; 25(1):173.
[49] Gattinoni L, Marini JJ, Busana M, Chiumello D, Camporota L. Spontaneous breathing, transpulmonary pressure and mathematical trickery. Ann Intensive Care. 2020; 10(1):88.
[50] Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D. COVID-19 does not lead to a “typical” acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020; 201(10): 1299-300.
[51] Tobin MJ. Principles and practice of mechanical ventilation. 3rd ed. New York: McGraw Hill; 2013. p. 3–1516.
[52] Hussain Khan Z, Sasaa MA, Mohammadi M, Alipour A, Hajipour A. Mortality Related to Intubation in Adult General ICUs: A Systematic Review and Meta-Analysis. Arch Neurosci. 2020;7(3).
IssueVol 8 No 1 (2022): Winter QRcode
SectionReview Article(s)
Coronavirus invasive ventilation non-invasive ventilation tracheal intubation intubation rapid sequence induction critical care

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How to Cite
Khan Z, AL-Dulaimi A, Varpaei HA, Mohammadi P, Mohammadi M. Early versus delayed intubation and technique in COVID-19. Arch Anesth & Crit Care. 2022;8(1):60-67.