Emulating Target Trials Comparing Early and Delayed Intubation Strategies
The appropriateness of initiating intubation early in critically ill patients has been a topic of contention, with previous observational studies yielding ambiguous results due to various flaws such as immortal time bias, unfitting eligibility criteria, and unrealistic treatment strategies. This study aimed to discern if treatment strategies that promote early intubation upon critical care admission enhance 30-day survival as opposed to those that advocate for delayed intubation. Leveraging data from the Medical Information Mart for Intensive Care-IV database, three target trials were emulated, each differing in treatment strategy flexibility and baseline eligibility criteria. The findings revealed that under exceedingly strict treatment strategies coupled with broad eligibility criteria, the 30-day mortality risk was 7.1 percentage points higher for early intubation than for delayed intubation (95% CI, 6.2-7.9). However, subsequent target trial emulations with more pragmatic treatment strategies and eligibility criteria displayed risk differences of 0.4 (95% CI, –0.1 to 0.9) and –0.9 (95% CI, –2.5 to 0.7) percentage points. In essence, when employing realistic treatment and eligibility guidelines, delaying intubation yielded comparable 30-day mortality rates to early intubation, with the added advantage of averting intubation in a majority of patients.