• Kerollos Nashat Wanis, Arin L Madenci, Sicheng Hao, Mira Moukheiber, Lama Moukheiber, Dana Moukheiber, Sulaiman Moukheiber, Jessica G Young, and Leo Anthony Celi.
• Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA; Division of General Surgery, Department of Surgery, Western University, London, ON, Canada. Electronic address: knwanis@g.harvard.edu.
• Chest. 2023 Oct 1; 164 (4): 885891885-891.

BackgroundWhether 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 QuestionDo treatment strategies that intubate patients early in the critical care admission improve 30-day survival compared with strategies that delay intubation?Study Design And MethodsWe 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.ResultsUnder 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.InterpretationWhen 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.Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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