In my limited experience, the dictum is still very patient dependent. other factors are also important and need to be taken into account; age, respiratory reserve. Some patients in fact do well on non-invasive and HFNC.

To the best of my knowledge there is no additional benefit with early intubation, as the evidence evolves maybe we will have more (different) information.

I recommend intubation when indicated by standard non-COVID-19 related parameters. There is no compelling evidence that COVID-19 should be treated differently to any other viral pneumonia.

Intrested

Please read the artcile in link:

DOI: 10.36648/2471-8505.6.2.7

Those patient who can be managed on HFNC/ rebreather mask/CPAP with negative pressure room or helmet CPAP and maintaining PO2 more than 55% should not be intubated. Can be additionally supported with proning and mild sedation like quitiepine or dexmedetomidine if agitated. Since this viral pneumonia is an organizing pnuemonia, those who are intubated early spent many days on mechanical ventilation and suffer Ventilator associated pnuemonia and associated other complications.

Late intubation.

Dear Shamim Kausar

You wrote ..."maintaining PO2 more than 55%"... Did you nean SpO2?

In my opinion ,covid 19 patients to be maintained on BIPAP / HFNO as far as possible . If not maintaining , then invasive ventilation is the only option.

Early and/or late intubation in COVID-19 patients is a generally, one of the main questions. But, some recommendations could be noted.

First, as late as possible is recommended from the beginning of pandemic crisis. All intubated patients are for the long time on ventilators (at least two-three weeks). In that time, VAP or some other infections may complicate the outcome of those patients.

Second, if the patients are working well on NIV or HFNC, often putting the patients in prone position is mandatory and helps in improvement of global patients’ oxygenation. But, sometimes (unfortunately, very often in this second pandemic wave) patients need intubation, because of progression of respiratory dysfunction, prone position is not sufficient to insure adequate oxygenation.

When is the best moment to intubate? I recommend to use ROX index, by whom you can estimate the time for intubation. It is very simple to calculate, you need patients’ SpO2, FiO2 across HFNC and respiratory frequency. Predictors of HFNC failure include:

ROX

Early and/or late intubation in COVID-19 patients is a generally, one of the main questions. But, some recommendations could be noted.

First, as late as possible is recommended from the beginning of pandemic crisis. All intubated patients are for the long time on ventilators (at least two-three weeks). In that time, VAP or some other infections may complicate the outcome of those patients.

Second, if the patients are working well on NIV or HFNC, often putting the patients in prone position is mandatory and helps in improvement of global patients’ oxygenation. But, sometimes (unfortunately, very often in this second pandemic wave) patients need intubation, because of progression of respiratory dysfunction, prone position is not sufficient to insure adequate oxygenation.

When is the best moment to intubate? I recommend to use ROX index, by whom you can estimate the time for intubation. It is very simple to calculate, you need patients’ SpO2, FiO2 across HFNC and respiratory frequency. Predictors of HFNC failure include:

ROX

@ Nikola Bradic

This is PO2. Which is tested in arterial blood gas sample only. If one really want to target SPO2 ...then 88% above is fair enough.

Intrested

Dear Shamim Kausar

I know that, but you wrote PO2 55%, not mmHg. I was confused about that.

Thanks on your answer

@ Nikola Bradic

Thanks that you highlighted. Yes I should have written mmHg. Your this effort must have cleared the things to others as well. Thanks again

There are currently no evidence based guidelines describing when to pursue intubation and mechanical ventilation. In clinical practice, a combination of factors in deciding when to intubate.

Please see further manuscript.

Best

Thank you! Dr. Bradic.

If patient is not improving on HFNC and NIV in a day or two and FiO2 is on the increase specially more than .6. Then its advisable to intubate patient and put him in prone position.

Rest treatment will be antiviral, low dose steroid, anticoagulants, and judicious fluid therapy.

24 to 48 hrs on HFNC or NIV ventilation with Prone positioning. if no signs of improvement, better go with Intubation and prone ventilation

Deciding when to intubate (very) early in our prehospital service is quite a tricky question for my colleagues and me and has been since the pandemic started. Our current strategy is to avoid intubation for the transport to hospital, if the patient shows a positive response to supplamental oxygen. ( a rapid sO2 increase to levels above 88-89%). To that end we had been from the beginning prone to using NIV for the transport. To avoid crew contamination as much as possible we are standardly using NIV Helmets instead of masks

I working on that

infact no intubation, just put well sealed NIV mask and let patient maintain saturation or retain carbon dioxide, i found lung improved however if put on invasive chances of death is 100 %

Depending on the patient's condition, their oxygenation levels, etc. There cannot be a single and standard answer without analyzing each patient ... but, even if this patient needs help in his breathing, it is not the same "glasses" for oxygen -introduced through the endonasal route-, than intubation and oxygen cylinder : THERE ARE SICK, NO ILLNESS!

Many of us are doing late intubation and maintaining patients on NIV. If patient is requiring high pressure supports to maintain his saturation and his work of breathing is more, I think this is the time to intubate. Moreover we need to have some guidelines on this .

There is a approach called "Timely Intubation". We need a data on - Out of how many patients those who were put on NIV , survived as compared to those who were timely intubated and properly cared , survived.

Yes timely intubation is very important. If your pt is on NIV, you need to define when you are going to intubate your patient. If you allow your patient on NIV even when fiO2 is 1.0 It means there is no recruitable lung because of self-inflicted Lung injury(SILI). It means it's a late intubation you are going to have worst patient outcome. There have studies that says if you intubate your patient early (means with out SILI), that outcome is going to be favorable.

I preferred late intubation, due to reasons I explained earlier. But, the best way to estimate right time for intubation is the status of chest X-rays/CT scan of the patients’ lungs. If the lungs are infiltrated more than 60%, you cannot make recruitment by NIV without dangerous of pneumothorax and/or pneumomediastinum. Further problem is the CO2 retention which is the additional difficult in ventilation (due to destruction of lung membrane). Very difficult to cure, and you need to assess each patient individually. If you have possibility to put the patient on ECMO treatment, late intubation or prolonged NIV/HFNC therapy could be even undesirable.

One has to decide what is early vs Late intubation, there should some objective guiding factors to take decision to intubate. When in doubt dictum is intubate the patient.