Timing of mechanical ventilation in sepsis

To the editor,

A recent study [1] by Dr. Kim and colleagues examined the association between the timing of mechanical ventilation (MV) and clinical outcomes in ICU patients with sepsis. The study included 2440 adult sepsis patients from 20 hospitals in Korea. Results showed that the early MV group had lower in-hospital mortality, shorter ICU stays, and less tracheostomy rate compared to the delayed MV group, suggesting that early MV may benefit sepsis patients. However, certain considerations should be taken into account when interpreting these findings.

First, the reason for MV in sepsis patients may contribute to the differences observed between the early and delayed MV groups. Not all ICU-admitted sepsis patients require intubation, with respiratory failure or acute respiratory distress syndrome (ARDS) being common reasons for intubation in this population. Thus, baseline differences, particularly the higher prevalence of primary respiratory infections in the early MV group, may partly explain the observed mortality benefits. Compared to the delayed MV group, the early MV group had a significantly higher rate of respiratory infections (1256/2119 [59.3%] vs. 126/321 [39.3%], p < 0.01), which is a major cause of acute respiratory failure and possibly prompting early intubation. In contrast, patients in the delayed MV group may not initially have pulmonary involvement but developed complications such as ARDS or multiple organ dysfunction syndrome (MODS) as their disease progressed. In this case, the differences between the early and delayed MV groups are more likely due to differences in disease status rather than the timing of intubation itself.

Second, regarding clinical applicability, the study’s inclusion criteria limit its generalizability to other sepsis patients, as not all sepsis patients require intubation. For example, in the current study, 2363 of 4890 patients admitted with sepsis did not require MV during their ICU stay and were excluded from the analysis. Thus, while this study highlights the potential benefits of early MV, it does not clarify which sepsis patients require MV, and simply applying early MV protocol could lead to unnecessary intubation.

While early MV may be beneficial for sepsis patients with respiratory involvement, a one-size-fits-all approach could lead to suboptimal patient management. Future studies should explore more refined criteria for early versus late MV in sepsis. Stratifying patients by risk factors may help better elucidate the benefits of early MV and prevent unnecessary intubations. Additionally, assessing other respiratory support methods, such as high-flow nasal cannula (HFNC) or non-invasive ventilation (NIV), as interim measures before invasive intubation could improve outcomes for patients who might avoid mechanical ventilation altogether.

In conclusion, while this study suggests an association between early MV and reduced mortality in sepsis, careful patient selection is essential. Finally, we commend Dr. Kim and colleagues for their significant contribution, and we hope our perspectives aid in the interpretation of these findings.

No datasets were generated or analysed during the current study.

1. Kim G, Oh DK, Lee SY, Park MH, Lim CM. Korean sepsis alliance I: impact of the timing of invasive mechanical ventilation in patients with sepsis: a multicenter cohort study. Crit Care. 2024;28(1):297.

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Authors and Affiliations

1. Department of Intensive Care, Zhejiang Hospital, No. 1229, Gudun Road, Hangzhou, 310013, Zhejiang, People’s Republic of China

   Juqin Shao & Juan Lin

2. Intensive Care Unit, Zhejiang Hospital, 12# Linyin Road, Hangzhou City, 310013, Zhejiang Province, People’s Republic of China

   Juan Lin

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Juqin Shao raised the question and Juan Lin wrote the letter. All authors have reviewed and approved the letter.

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Correspondence to Juan Lin.

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Shao, J., Lin, J. Timing of mechanical ventilation in sepsis. Crit Care 28, 397 (2024). https://doi.org/10.1186/s13054-024-05179-5

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• Received: 12 November 2024

• Accepted: 15 November 2024

• Published: 29 November 2024

• DOI: https://doi.org/10.1186/s13054-024-05179-5

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