CRITICAL CARE: ORIGINAL RESEARCH| VOLUME 164, ISSUE 4, P885-891, OCTOBER 2023

Emulating Target Trials Comparing Early and Delayed Intubation Strategies

Kerollos Nashat Wanis, Arin L. Madenci, Sicheng Hao, et al

Chest 2023; 164: 885-891 Published: May 05, 2023

DOI: https://doi.org/10.1016/j.chest.2023.04.048

Background

Whether intubation should be initiated early in the clinical course of critically ill patients remains a matter of debate. Results from prior observational studies are difficult to interpret because of avoidable flaws including immortal time bias, inappropriate eligibility criteria, and unrealistic treatment strategies.

Research Question

Do treatment strategies that intubate patients early in the critical care admission improve 30-day survival compared with strategies that delay intubation?

Study Design and Methods

We estimated the effect of strategies that require early intubation of critically ill patients compared with those that delay intubation. With data extracted from the Medical Information Mart for Intensive Care-IV database, we emulated three target trials, varying the flexibility of the treatment strategies and the baseline eligibility criteria.

Results

Under unrealistically strict treatment strategies with broad eligibility criteria, the 30-day mortality risk was 7.1 percentage points higher for intubating early compared with delaying intubation (95% CI, 6.2-7.9). Risk differences were 0.4 (95% CI, –0.1 to 0.9) and –0.9 (95% CI, –2.5 to 0.7) percentage points in subsequent target trial emulations that included more realistic treatment strategies and eligibility criteria.

Interpretation

When realistic treatment strategies and eligibility criteria are used, strategies that delay intubation result in similar 30-day mortality risks compared with those that intubate early. Delaying intubation ultimately avoids intubation in most patients.