CHESTCOVID-19 Resource CenterTiming of Intubation in Patients With COVID-19

Timing of Intubation in Patients With COVID-19


This CHEST series highlights specific studies in the COVID-19 literature that may warrant discourse or reading for members of the chest medicine community. Articles are written by members of CHEST Networks. You can read additional articles in this series.

NOTE: The perspectives shared in this article are those of the author(s) and not those of CHEST.

Timing of Intubation in Patients With COVID-19

By: Casey Cable, MD, MSc; David Bell, MD; Alice Gallo de Moraes, MD; and Viren Kaul, MD
Critical Care Network

Published: March 16, 2021

The timing of intubation in hypoxemic patients with COVID-19 has been hotly debated. Early in the pandemic, there was a push to intubate early, driven by the effort to reduce transmission of the virus. With time, high-flow nasal cannula (HFNC) oxygenation and noninvasive ventilation (NIV) have been proven safe in terms of transmission of the virus when precautions are taken and have been used as support to avoid intubation when appropriate, as reflected in recommendations by the updated Surviving Sepsis Guidelines.1,2 However, the clinical question persists: When is the “right time” to intubate hypoxemic patients with COVID-19?

Physical examination is the most effective diagnostic tool when assessing for respiratory distress in the setting of hypoxemia, as oxygen saturations alone are poor indicators of the need for mechanical ventilation. As Tobin explains, the decision to intubate should be based on amalgamation of oxygen saturation and physiological effects of hypoxia, including tachypnea and work of breathing. Work of breathing can be assessed by evaluation of the accessory muscle use, including the palpation of sternocleidomastoids, scalene contraction, abdominal muscle contraction, and tracheal tugging. Similarly, paying attention to signs of distress such as nasal flaring and gasping is important.3 Asking for the patient’s input is similarly useful in determining the need for mechanical ventilation. A patient who is breathing comfortably and able to talk in full sentences is unlikely to be in such distress that urgent intubation is needed.4 The Cabrini Respiratory Strain Scale measures these observable variables and is being studied as a decision tool for invasive ventilation.5

Having defined tools that assist clinicians in deciding when to intubate patients in general, what does “late” and “early” really mean in the course of COVID-19 lung injury? Since invasive ventilation does not heal lungs, the optimal timing of intubation in COVID-19 would reduce the net risk of patient self-inflicted lung injury, ventilator-induced lung injury, nosocomial infections, the intubation procedure, and transmission of the infection to others.

Delayed intubation may increase the risks of peri-procedural arrest if the delay results in worsened hypoxemia and lack of preoxygenation,6 which favors careful planning regardless of strategy. Previous work in hypoxemic respiratory failure with and without ARDS suggests worse outcomes with delays in intubation when compared to intubation at the time of admission to ICU7 or diagnosis of ARDS.8

A retrospective study from four university-affiliated hospitals in Atlanta, Georgia, evaluated 231 patients admitted to the ICU with COVID-19 and found no association with mortality, duration of ventilation, or ICU length of stay between timing of intubation within the first 24 hours of ICU admission9 (<8, 8-24, >24). Dupuis and colleagues performed a prospective multicenter observational study, including 245 ICU patients across 11 ICUs in France.9 Rates of ICU-acquired pneumonia, bacteremia, and ICU length of stay were significantly higher if patients were intubated within the first 2 calendar days of ICU stay, as was the 60-day mortality (weighted hazard ratio: 1.74, 95% CI, 1.07-2.83, p = .03). Similarly, no difference in mortality has also been noted in smaller observational studies10,11; and one recent study showed longer ICU stays for late intubations.12

In summary, the current evidence does not show meaningful differences in outcomes in patients with early or late endotracheal intubations. Ultimately, the decision on when to intubate should be based on the clinical gestalt of an experienced intensivist, encompassing not only the oxygenation status but also the degree of respiratory distress, based on clinical evaluation of the work of breathing.


  1. Odor PM, Neun M, Bampoe S, et al. Anaesthesia and COVID-19: infection control. British Journal of Anaesthesia. 2020;125(1):16-24.
  2. Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Crit Care Med. 2020;48(6):101.
  3. Tulaimat A, Patel A, Wisniewski M, et al. The validity and reliability of the clinical assessment of increased work of breathing in acutely ill patients. J Crit Care. 2016;34:111-115.
  4. Tobin MJ. Why physiology is critical to the practice of medicine: a 40-year personal perspective. Clin Chest Med. 2019;40(2):243–257.
  5. Rola P, Farkas J, Spiegel R, et al. Rethinking the early intubation paradigm of COVID-19: time to change gears? Clin Exp Emerg Med. 2020;7(2):78-80.
  6. De Jong A, Rolle A, Molinari N, et al. Cardiac arrest and mortality related to intubation procedure in critically ill adult patients: a multicenter cohort study. Crit Care Med. 2018;46(4):532-539.
  7. Bauer PR, Kumbamu A, Wilson ME, et al. Timing of intubation in acute respiratory failure associated with sepsis: a mixed methods study. Mayo Clin Proc. 2017;92(10):1502-1510.
  8. Kangelaris KN, Ware LB, Wang CY, et al. Timing of intubation and clinical outcomes in adults with ARDS. Crit Care Med. 2016;44(1):120-129.
  9. Dupuis C, Bouadma L, de Montmollin E, et al. Association between early invasive mechanical ventilation and day-60 mortality in acute hypoxemic respiratory failure related to coronavirus disease-2019 pneumonia. Critical Care Explorations. 2021;3(1):e0329.
  10. Lee YH, Choi K-J, Choi SH, et al. Clinical significance of timing of intubation in critically ill patients with COVID-19: a multi-center retrospective study. J Clin Med. 2020;9(9).
  11. Siempos II, Xourgia E, Ntaidou TK, et al. Effect of early vs delayed or no intubation on clinical outcomes of patients with COVID-19: an observational study. Front Med (Lausanne). 2020;7:614152.
  12. Pandya A, Kaur NA, Sacher D, 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.

Casey Cable, MD, MSc

Casey Cable, MD, MSc

• Pulmonary and Critical Care Medicine Physician at Virginia Commonwealth University Health in Richmond
• Clinical interests include mechanical ventilation, sepsis, and rapid response

Alice Gallo de Moraes, MD

Alice Gallo de Moraes, MD

• Pulmonary and Critical Care Medicine Physician at Mayo Clinic in Rochester, MN
• Clinical interests include mechanical ventilation, liver failure in the ICU, and ICU-related complications of novel oncologic treatments

Viren Kaul, MD

Viren Kaul, MD

• Pulmonary and Critical Care Medicine Physician at Crouse Health and Assistant Professor of Medicine at SUNY Upstate Medical University in Syracuse, NY
• Clinical interests include airway and mechanical ventilation management in critically ill patients, pleural diseases, interstitial lung diseases, and pulmonary hypertension

David Bell, MD

• Pulmonary and Critical Care Medicine Physician at the South Texas Veterans Health Care System in San Antonio
• Clinical interests include airway management, sepsis, and mechanical ventilation

Read more COVID in Focus: Perspectives on the Literature:

Asthma and COVID-19 - Airways Disorders Network

Obstructive Sleep Apnea as a Risk Factor for Adverse Outcomes in COVID-19 - Sleep Medicine Network