Nationwide assessment of COVID-19 ventilator and non-invasive respiratory support burden during the early pandemic in the United States

In this nationwide cross-sectional study of 4,055,462 hospital admissions with a diagnosis of coronavirus disease 2019 (COVID-19) from April 2020 to December 2021 identified in the Agency of Healthcare Research and Quality's Healthcare Cost and Utilization Project National Inpatient Sample in the United States, a total of 489,390 (12.1%) patients experienced endotracheal intubation and mechanical ventilation, with the highest peak in August 2021 (48,735 endotracheal intubations and mechanical ventilation), followed by January 2021 (47,100 endotracheal intubations and mechanical ventilation) and December 2021 (43,835 endotracheal intubations and mechanical ventilation). During the 3-month long large surge from November 2020 to January 2021, a total of 104,750 endotracheal intubations and mechanical ventilation occurred among 1,069,874 COVID-19 admissions. Shock (adjusted-odds ratio 24.21, 95% confidence interval 23.93-24.49) and respiratory failure (adjusted-odds ratio 14.09, 95% confidence interval 13.80-14.38) were the two strongest factors associated with endotracheal intubation and mechanical ventilation. A total of 266,585 (6.6%) patients received non-invasive respiratory support alone without endotracheal intubation and mechanical ventilation during the study period with the highest peak in August 2021 (30,725 cases), followed by January 2021 (28,035 cases), and December 2021 (26,200 cases). The utilization of non-invasive respiratory support without endotracheal intubation and mechanical ventilation increased by nearly three-fold during the 21-month study period (adjusted-odds ratio for the fourth year-quarter of 2021 compared to the second year-quarter of 2020 2.94, 95% confidence interval 2.88-3.00). A total of 515,800 (12.7%) deaths occurred during COVID-19 hospitalization, with highest in the peak of multi-month lasting largest surge (January 2021, 56,775 deaths), followed by August 2021 (47,535 deaths) and December 2021 (46,880 deaths). Among those who deceased following endotracheal intubation and mechanical ventilation, the median time from admission to death was 14 days (interquartile range 7-21). COVID-19 admissions, respiratory intervention approach, and COVID-19 case fatality differed across the nine U.S. census divisions during the study period. In conclusion, these statistics may be useful to inform the national-level preparedness of global pandemic from respiratory illness in the future, possibly exceeding 48,000 endotracheal intubations and mechanical ventilation across the country in a month and 100,000 endotracheal intubations and mechanical ventilation in three months when encountering long-lasting surge with one-million admissions.