PurposeTo investigate if the timing of initiation of invasive mechanical ventilation (IMV) for critically ill patients with COVID-19 is associated with mortality.Materials and methodsThe data for this study were derived from a multicenter cohort study of critically ill adults with COVID-19 admitted to ICUs at 68 hospitals across the US from March 1 to July 1, 2020. We examined the association between early (ICU days 1–2) versus late (ICU days 3–7) initiation of IMV and time-to-death. Patients were followed until the first of hospital discharge, death, or 90 days. We adjusted for confounding using a multivariable Cox model.ResultsAmong the 1879 patients included in this analysis (1199 male [63.8%]; median age, 63 [IQR, 53–72] years), 1526 (81.2%) initiated IMV early and 353 (18.8%) initiated IMV late. A total of 644 of the 1526 patients (42.2%) in the early IMV group died, and 180 of the 353 (51.0%) in the late IMV group died (adjusted HR 0.77 [95% CI, 0.65–0.93]).ConclusionsIn critically ill adults with respiratory failure from COVID-19, early compared to late initiation of IMV is associated with reduced mortality.