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Emulating Target Trials Comparing Early and Delayed Intubation Strategies
Kerollos Nashat Wanis1, Arin L Madenci2, Sicheng Hao3
1Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA; Division of General Surgery, Department of Surgery, Western University, London, ON, Canada.
Chest
|May 7, 2023
Summary
Early intubation in critical care may increase 30-day mortality. Realistic strategies show delaying intubation offers similar survival benefits and avoids unnecessary procedures for critically ill patients.
Area of Science:
- Critical Care Medicine
- Clinical Trial Emulation
- Health Services Research
Background:
- Debate exists regarding early endotracheal intubation for critically ill patients.
- Prior observational studies have limitations, including bias and flawed methodologies.
- The optimal timing for intubation in intensive care remains unclear.
Purpose of the Study:
- To compare 30-day survival between early and delayed intubation strategies in critical care.
- To emulate target trials using real-world data to assess intubation timing effects.
- To investigate the impact of varying treatment flexibility and eligibility criteria on outcomes.
Main Methods:
- Emulation of three target trials using data from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database.
- Comparison of early intubation versus delayed intubation strategies.
- Analysis of 30-day mortality risk differences under different treatment and eligibility scenarios.
Main Results:
- Under strict, broad criteria, early intubation was associated with a 7.1% higher 30-day mortality risk.
- More realistic strategies showed minimal risk differences (0.4% and -0.9%) between early and delayed intubation.
- Delayed intubation strategies resulted in similar 30-day mortality risks compared to early intubation.
Conclusions:
- Realistic treatment strategies indicate that delaying intubation yields comparable 30-day survival to early intubation.
- Delaying intubation can avoid the procedure in a significant proportion of critically ill patients.
- Evidence supports exploring delayed intubation as a viable strategy in critical care settings.
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