Controversies in airway management of COVID-19 patients: updated information and international expert consensus recommendations

Abstract

As knowledge and experience in the management of critically ill coronavirus disease 2019 (COVID-19) patients has increased with time, a panel of international experts convened and formulated consensus opinions regarding controversial topics in advanced airway management based on current literature. Here we summarise updated information and international expert opinion on several controversial topics concerning airway management in critically ill patients with COVID-19. Recommendations for the personal protective equipment (PPE) required during aerosol-generating procedures (AGPs), such as advanced airway management, are inconsistent amongst different countries and regions.1Cook T.M. El-Boghdadly K. McGuire B. McNarry A.F. Patel A. Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists.Anaesthesia. 2020; 75: 785-799Crossref PubMed Scopus (570) Google Scholar, 2Brewster D.J. Chrimes N. Do T.B. Fraser K. Groombridge C.J. Consensus statement: safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group.Med J Aust. 2020; 212: 472-481Crossref PubMed Scopus (249) Google Scholar, 3Zuo M.Z. Huang Y.G. Ma W.H. et al.Expert recommendations for tracheal intubation in critically ill patients with noval coronavirus disease 2019.Chin Med Sci J. 2020; 35: 105-109Google Scholar, 4US Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. Available online at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. [Accessed 18 November 2020].Google Scholar, 5World Health Organization Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19): interim guidance,.19 March 2020https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdfDate accessed: November 18, 2020Google Scholar, 6Public Health EnglandCOVID-19: infection prevention and control.2020https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-controlDate accessed: November 18, 2020Google Scholar, 7European Centre for Disease Prevention and Control (ECDC)Personal protective equipment (PPE) needs in healthcare settings for the care of patients with suspected or confirmed novel coronavirus (2019-nCoV).Feb 7, 2020https://www.ecdc.europa.eu/sites/default/files/documents/novel-coronavirus-personal-protective-equipment-needs-healthcare-settings.pdfDate accessed: September 8, 2020Google Scholar, 8Şentürk M. El Tahan M.R. Szegedi L.L. et al.Thoracic anesthesia of patients with suspected or confirmed 2019 novel coronavirus infection: preliminary recommendations for airway management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee.J Cardiothorac Vasc Anesth. 2020; 34: 2315-2327Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Two new studies report conflicting results, either supporting9Dhillon R.S. Rowin W.A. Humphries R.S. et al.Aerosolisation during tracheal intubation and extubation in an operating theatre setting.Anaesthesia. 2020; (Access Published October 12)https://doi.org/10.1111/anae.15301. advanceCrossref PubMed Google Scholar or opposing10Brown J. Gregson F.K.A. Shrimpton A. et al.A quantitative evaluation of aerosol generation during tracheal intubation and extubation.Anaesthesia. 2020; (Advance Access Published October 6)https://doi.org/10.1111/anae.15292Crossref Scopus (103) Google Scholar tracheal intubation and extubation as AGPs. Both studies were limited by small sample size, and used different definitions of AGPs and particle detection methods. Additional carefully designed studies are necessary to clarify the risk of aerosolised viral spread during tracheal intubation and extubation. In the interim, it is prudent to continue to consider both as AGPs. Maximal interventions to safeguard healthcare workers from cross infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) must be maintained until this question is adequately studied. Studies from China have classified levels of PPE (Fig 1).11Liu Z. Wu Z. Zhao H. Zuo M. Personal protective equipment during tracheal intubation in patients with COVID-19 in China: a cross-sectional survey.Br J Anaesth. 2020; 125: e420-e422Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Level III has been reported to protect healthcare workers from cross infection during a variety of AGPs including tracheal intubation (Table 1),11Liu Z. Wu Z. Zhao H. Zuo M. Personal protective equipment during tracheal intubation in patients with COVID-19 in China: a cross-sectional survey.Br J Anaesth. 2020; 125: e420-e422Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar,12Yao W. Wang T. Jiang B. et al.Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.Br J Anaesth. 2020; 125: e28-e37Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar,14Cai S.J. Wu L.L. Chen D.F. et al.[Analysis of bronchoscope-guided tracheal intubation in 12 cases with coronavirus disease 2019 under the personal protective equipment with positive pressure protective hood].Zhonghua Jie He He Hu Xi Za Zhi. 2020; 43: 332-334PubMed Google Scholar,15Wu C.N. Xia L.Z. Li K.H. et al.High-flow nasal-oxygenation-assisted fibreoptic tracheal intubation in critically ill patients with COVID-19 pneumonia: a prospective randomised controlled trial.Br J Anaesth. 2020; 125: e166-e168Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar high-flow nasal oxygen (HFNO) usage and tracheal intubation using a flexible intubating endoscope in patients with COVID-19.15Wu C.N. Xia L.Z. Li K.H. et al.High-flow nasal-oxygenation-assisted fibreoptic tracheal intubation in critically ill patients with COVID-19 pneumonia: a prospective randomised controlled trial.Br J Anaesth. 2020; 125: e166-e168Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Level II PPE, often used in other countries and regions outside China,4US Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. Available online at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. [Accessed 18 November 2020].Google Scholar,5World Health Organization Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19): interim guidance,.19 March 2020https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdfDate accessed: November 18, 2020Google Scholar,7European Centre for Disease Prevention and Control (ECDC)Personal protective equipment (PPE) needs in healthcare settings for the care of patients with suspected or confirmed novel coronavirus (2019-nCoV).Feb 7, 2020https://www.ecdc.europa.eu/sites/default/files/documents/novel-coronavirus-personal-protective-equipment-needs-healthcare-settings.pdfDate accessed: September 8, 2020Google Scholar may not provide full protection from cross infection. Cross infection rates in healthcare workers range from 0% to 14.7% (Table 1).27Feldman O. Meir M. Shavit D. Idelman R. Shavit I. Exposure to a surrogate measure of contamination from simulated patients by emergency department personnel wearing personal protective equipment.JAMA. 2020; 323: 2091-2093Crossref PubMed Scopus (63) Google Scholar,28Cook T.M. Risk to health from COVID-19 for anaesthetists and intensivists — a narrative review.Anaesthesia. 2020; 75 (Published July 17): 1494-1508https://doi.org/10.1111/anae.15220. Advance AccessCrossref PubMed Scopus (0) Google Scholar The primary difference between level II and III PPE is that level III includes use of a face shield, eye goggles, water-resistant gown, and hooded coverall. This assists in avoiding exposure of skin or eyes to air and potentially aerosolised viral particles (Fig 1). Table 2 summarises the commonly used levels of PPE around the world and the reported cross infection rates in healthcare workers. Videolaryngoscopy is the recommended approach for tracheal intubation in patients with COVID-19 in order to maximise first pass success rate and minimise exposure of healthcare workers during the procedure.1Cook T.M. El-Boghdadly K. McGuire B. McNarry A.F. Patel A. Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists.Anaesthesia. 2020; 75: 785-799Crossref PubMed Scopus (570) Google Scholar,12Yao W. Wang T. Jiang B. et al.Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.Br J Anaesth. 2020; 125: e28-e37Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar,13Meng L. Qiu H. Wan L. et al.Intubation and ventilation amid the COVID-19 outbreak: wuhan's experience.Anesthesiology. 2020; 132: 1317-1332Crossref PubMed Scopus (355) Google Scholar Awake tracheal intubation (ATI) has been performed successfully using flexible bronchoscopy. To date, cross infection of healthcare workers has not been reported during ATI. Therefore, ATI should be considered for management of the anticipated difficult airway, especially when tracheal intubation under general anaesthesia is considered unsafe.14Cai S.J. Wu L.L. Chen D.F. et al.[Analysis of bronchoscope-guided tracheal intubation in 12 cases with coronavirus disease 2019 under the personal protective equipment with positive pressure protective hood].Zhonghua Jie He He Hu Xi Za Zhi. 2020; 43: 332-334PubMed Google Scholar Level III PPE should be used.Table 1Healthcare workers cross infection rate at different levels of personal protective equipment. ∗Tracheal intubation and other aerosol generating procedures. †No infection in operators with Level III PPE. ‡Total cases were not reported. ¶Total infection rate among asymptomatic HCWs. §The rate listed is the incidence of laboratory-confirmed COVID-19 diagnosis or new symptoms requiring self-isolation or hospitalisation after a tracheal intubation episode. This study included intubation in known and suspected COVID-19 patients. HCW, healthcare worker; PPE, personal protective equipment.Infection rate of HCWs after tracheal intubationOverall infection rate of HCWsProportion of HCWs in confirmed COVID-19 casesChinaLack of protection Meng and colleagues13Meng L. Qiu H. Wan L. et al.Intubation and ventilation amid the COVID-19 outbreak: wuhan's experience.Anesthesiology. 2020; 132: 1317-1332Crossref PubMed Scopus (355) Google Scholar29% (40/138)Level I Lai and colleagues16Lai X. Wang M. Qin C. et al.Coronavirus disease 2019 (COVID-2019) infection among health care workers and implications for prevention measures in a tertiary hospital in Wuhan, China.JAMA Netw Open. 2020; 3e209666Crossref PubMed Scopus (265) Google Scholar1.4% (93/6574)Level II Lai and colleagues16Lai X. Wang M. Qin C. et al.Coronavirus disease 2019 (COVID-2019) infection among health care workers and implications for prevention measures in a tertiary hospital in Wuhan, China.JAMA Netw Open. 2020; 3e209666Crossref PubMed Scopus (265) Google Scholar0.5% (17/3110)Level III3Zuo M.Z. Huang Y.G. Ma W.H. et al.Expert recommendations for tracheal intubation in critically ill patients with noval coronavirus disease 2019.Chin Med Sci J. 2020; 35: 105-109Google Scholar Wu and colleagues15Wu C.N. Xia L.Z. Li K.H. et al.High-flow nasal-oxygenation-assisted fibreoptic tracheal intubation in critically ill patients with COVID-19 pneumonia: a prospective randomised controlled trial.Br J Anaesth. 2020; 125: e166-e168Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar0% (0/6) Cai and colleagues14Cai S.J. Wu L.L. Chen D.F. et al.[Analysis of bronchoscope-guided tracheal intubation in 12 cases with coronavirus disease 2019 under the personal protective equipment with positive pressure protective hood].Zhonghua Jie He He Hu Xi Za Zhi. 2020; 43: 332-334PubMed Google Scholar0% (0/9) Yao and colleagues12Yao W. Wang T. Jiang B. et al.Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.Br J Anaesth. 2020; 125: e28-e37Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar0% (0/52) Liu and colleagues17Liu M. Cheng S.Z. Xu K.W. et al.Use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in Wuhan, China: cross sectional study.BMJ. 2020; 369: m2195Crossref PubMed Scopus (138) Google Scholar0% (0/420)∗Levels I–III Liu and colleagues11Liu Z. Wu Z. Zhao H. Zuo M. Personal protective equipment during tracheal intubation in patients with COVID-19 in China: a cross-sectional survey.Br J Anaesth. 2020; 125: e420-e422Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar2% (11/554)† Wu and colleagues18Wu Z. McGoogan J.M. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention.JAMA. 2020; 323: 1239-1242Crossref PubMed Scopus (10609) Google Scholar3.8% (1716/44 672)ItalyLevel II7European Centre for Disease Prevention and Control (ECDC)Personal protective equipment (PPE) needs in healthcare settings for the care of patients with suspected or confirmed novel coronavirus (2019-nCoV).Feb 7, 2020https://www.ecdc.europa.eu/sites/default/files/documents/novel-coronavirus-personal-protective-equipment-needs-healthcare-settings.pdfDate accessed: September 8, 2020Google Scholar Livingston and Bucher19Livingston E. Bucher K. Coronavirus disease 2019 (COVID-19) in Italy.JAMA. 2020; 323: 1335Crossref PubMed Scopus (675) Google Scholar9% (2026/22 512) Li and colleagues20Li J. Fink J.B. Ehrmann S. High-flow nasal cannula for COVID-19 patients: low risk of bio-aerosol dispersion.Eur Respir J. 2020; 55: 2000892Crossref PubMed Scopus (156) Google Scholar>8% (>1116/13 882) Anelli and colleagues21Anelli F. Leoni G. Monaco R. et al.Italian doctors call for protecting healthcare workers and boosting community surveillance during covid-19 outbreak.BMJ. 2020; 368: m1254Crossref PubMed Scopus (62) Google Scholar9% (4824 HCWs)‡UKLevel II6Public Health EnglandCOVID-19: infection prevention and control.2020https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-controlDate accessed: November 18, 2020Google Scholar Treibel and colleagues22Treibel T.A. Manisty C. Burton M. et al.COVID-19: PCR screening of asymptomatic health-care workers at London hospital.Lancet. 2020; 395: 1608-1610Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar11% (44/400)¶USALevel II4US Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. Available online at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. [Accessed 18 November 2020].Google Scholar Sullivan and colleagues23Sullivan E.H. Gibson L.E. Berra L. Chang M.G. In-hospital airway management of COVID-19 patients.Crit Care. 2020; 24: 292Crossref PubMed Scopus (21) Google Scholar14.7% (508/3466) Morcuende and colleagues24Morcuende M. Guglielminotti J. Landau R. Anesthesiologists' and intensive care providers' exposure to COVID-19 infection in a New York City academic center: a prospective cohort study assessing symptoms and COVID-19 antibody testing.Anesth Analg. 2020; 131: 669-676Crossref PubMed Scopus (15) Google Scholar12.1% (11/91)South AfricaLevel II Mendelson and colleagues25Mendelson M. Bokolo L. Boutall A. et al.Clinical management of COVID-19: experiences of the COVID-19 epidemic from groote schuur hospital.S Afr Med J. 2020; 110: 968-972Crossref PubMed Scopus (14) Google Scholar0% (0/41)International (17 countries)Level II5World Health Organization Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19): interim guidance,.19 March 2020https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdfDate accessed: November 18, 2020Google Scholar El-Boghdadly and colleagues26El-Boghdadly K. Wong D.J.N. Owen R. et al.Risks to healthcare workers following tracheal intubation of patients with COVID-19: a prospective international multicentre cohort study.Anaesthesia. 2020; (Advance Access Published June 9)https://doi.org/10.1111/anae.15170Crossref Scopus (178) Google Scholar10.7% (184/1718)§ Open table in a new tab Table 2Studies on use of high-flow nasal oxygen (HFNO) therapy and risks of viral spread. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.AuthorsType of studySubjectDetailsRestrict useSantarpia and colleagues29Santarpia J.L. Rivera D.N. Herrera V.L. et al.Aerosol and surface contamination of SARS-CoV-2 observed in quarantine and isolation care.Sci Rep. 2020; 10: 12732Crossref PubMed Scopus (341) Google ScholarClinical observationSARS-CoV-2The highest concentrations of virus in air were recorded during oxygenation through a nasal cannula.Loh and colleagues30Loh N.W. Tan Y. Taculod J. et al.The impact of high-flow nasal cannula (HFNC) on coughing distance: implications on its use during the novel coronavirus disease outbreak.Can J Anaesth. 2020; 67: 893-894Crossref PubMed Scopus (77) Google ScholarSimulation studySARS-CoV-2HFNO increased the dispersion distance of cough-generated dropletsSupport useLeung and colleagues31Leung C.C.H. Joynt G.M. Gomersall C.D. et al.Comparison of high-flow nasal cannula versus oxygen face mask for environmental bacterial contamination in critically ill pneumonia patients: a randomized controlled crossover trial.J Hosp Infect. 2019; 101: 84-87Abstract Full Text Full Text PDF PubMed Scopus (108) Google ScholarRandomised controlled crossover trialGram-negative bacteriaHFNO was not associated with increased air or contact surface contamination by bacteria in ICU patientsHui and colleagues32Hui D.S. Chow B.K. Lo T. et al.Exhaled air dispersion during high-flow nasal cannula therapy versus CPAP via different masks.Eur Respir J. 2019; 53: 1802339Crossref PubMed Scopus (210) Google ScholarSimulation studyRespiratory virusHFNO with good interface fitting was associated with limited exhaled air dispersion of virusTran and colleagues33Tran K. Cimon K. Severn M. Pessoa-Silva C.L. Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review.PLoS One. 2012; 7e35797Crossref PubMed Scopus (1150) Google ScholarSystematic reviewSARS-CoVHFNO did not increase transmission risk significantlyRello and colleagues34Rello J. Pérez M. Roca O. et al.High-flow nasal therapy in adults with severe acute respiratory infection: a cohort study in patients with 2009 influenza A/H1N1v.J Crit Care. 2012; 27: 434-439Crossref PubMed Scopus (131) Google ScholarCohort studyH1N1vNo secondary infections in healthcare workers, nor nosocomial pneumonia occurred during HFNO therapyMiller and colleagues35Miller D.C. Beamer P. Billheimer D. et al.Aerosol risk with noninvasive respiratory Support in patients with COVID-19.J Am Coll Emerg Physicians Open. 2020; 1: 521-526Crossref Google ScholarVolunteer simulation studyAerosol productionNo significant difference in aerosol production between either HFNO and low-flow nasal cannulaNeutralityAgarwal and colleagues36Agarwal A. Basmaji J. Muttalib F. et al.High-flow nasal cannula for acute hypoxemic respiratory failure in patients with COVID-19: systematic reviews of effectiveness and its risks of aerosolization, dispersion, and infection transmission.Can J Anaesth. 2020; 67: 1217-1248Crossref PubMed Scopus (95) Google ScholarSystematic reviewSARS-CoV-2Unknown effects of HFNO on risk of virus spreading Open table in a new tab It appears that the higher the level of PPE used, the better the protection against cross infection. However, adequate protection of healthcare workers is often limited by the availability of PPE during a world pandemic. It is recommended to use the highest level of PPE available in the management of patients with COVID-19, especially during performance of high-risk AGPs such as tracheal intubation, extubation, or tracheostomy.1Cook T.M. El-Boghdadly K. McGuire B. McNarry A.F. Patel A. Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists.Anaesthesia. 2020; 75: 785-799Crossref PubMed Scopus (570) Google Scholar,12Yao W. Wang T. Jiang B. et al.Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.Br J Anaesth. 2020; 125: e28-e37Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar,17Liu M. Cheng S.Z. Xu K.W. et al.Use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in Wuhan, China: cross sectional study.BMJ. 2020; 369: m2195Crossref PubMed Scopus (138) Google Scholar,37Gosling A.F. Bose S. Gomez E. et al.Perioperative considerations for tracheostomies in the era of COVID-19.Anesth Analg. 2020; 131: 378-386Crossref PubMed Scopus (19) Google Scholar Fit testing and supervised donning and doffing of PPE remain critical steps in the avoidance of cross infection of healthcare workers. It is crucial to note that PPE must be a part of a comprehensive infection control strategy in order to be effective. Healthcare workers remain a precious resource in the fight against COVID-19.38Assunção M. More than 1,000 U.S. health workers have died of COVID-19; many were racial minorities, immigrants. New York Daily News, 2020 Aug 26https://www.nydailynews.com/coronavirus/ny-coronavirus-health-workers-died-covid-racial-minorities-immigrants-20200826-xklqztcr5ngylg2bkk3phj237y-story.htmlDate accessed: September 8, 2020Google Scholar Many guidelines initially prohibited or discouraged use of high-flow nasal oxygen (HFNO) therapy in patients with COVID-19, based on the potential risks of aerosol generation and viral spread.1Cook T.M. El-Boghdadly K. McGuire B. McNarry A.F. Patel A. Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists.Anaesthesia. 2020; 75: 785-799Crossref PubMed Scopus (570) Google Scholar The extent of this risk remains unresolved.36Agarwal A. Basmaji J. Muttalib F. et al.High-flow nasal cannula for acute hypoxemic respiratory failure in patients with COVID-19: systematic reviews of effectiveness and its risks of aerosolization, dispersion, and infection transmission.Can J Anaesth. 2020; 67: 1217-1248Crossref PubMed Scopus (95) Google Scholar Some studies support29Santarpia J.L. Rivera D.N. Herrera V.L. et al.Aerosol and surface contamination of SARS-CoV-2 observed in quarantine and isolation care.Sci Rep. 2020; 10: 12732Crossref PubMed Scopus (341) Google Scholar,30Loh N.W. Tan Y. Taculod J. et al.The impact of high-flow nasal cannula (HFNC) on coughing distance: implications on its use during the novel coronavirus disease outbreak.Can J Anaesth. 2020; 67: 893-894Crossref PubMed Scopus (77) Google Scholar use of HFNO whereas others do not (Table 2).31Leung C.C.H. Joynt G.M. Gomersall C.D. et al.Comparison of high-flow nasal cannula versus oxygen face mask for environmental bacterial contamination in critically ill pneumonia patients: a randomized controlled crossover trial.J Hosp Infect. 2019; 101: 84-87Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar, 32Hui D.S. Chow B.K. Lo T. et al.Exhaled air dispersion during high-flow nasal cannula therapy versus CPAP via different masks.Eur Respir J. 2019; 53: 1802339Crossref PubMed Scopus (210) Google Scholar, 33Tran K. Cimon K. Severn M. Pessoa-Silva C.L. Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review.PLoS One. 2012; 7e35797Crossref PubMed Scopus (1150) Google Scholar Use of HFNO in critically ill patients with COVID-19 with hypoxic respiratory insufficiency has been examined for its potential benefit as the mortality rate of mechanically ventilated patients remains high.39Bhatraju P.K. Ghassemieh B.J. Nichols M. et al.Covid-19 in critically ill patients in the Seattle region — case series.N Engl J Med. 2020; 382: 2012-2022Crossref PubMed Scopus (1588) Google Scholar Patients with COVID-19 with pulmonary failure but normal lung compliance appear to respond favourably to HFNO treatment, but those patients with impaired lung compliance may not derive the same benefit.40Gattinoni L. Chiumello D. Caironi P. et al.COVID-19 pneumonia: different respiratory treatments for different phenotypes?.Intensive Care Med. 2020; 46: 1099-1102Crossref PubMed Scopus (1023) Google Scholar A cohort study from the 2009 epidemic of respiratory failure caused by influenza A found that use of HFNO reduced the need for mechanical ventilation by 45%.34Rello J. Pérez M. Roca O. et al.High-flow nasal therapy in adults with severe acute respiratory infection: a cohort study in patients with 2009 influenza A/H1N1v.J Crit Care. 2012; 27: 434-439Crossref PubMed Scopus (131) Google Scholar The future use of HFNO in patients with COVID-19 will be based on its efficacy to diminish hypoxaemia, the need for mechanical ventilatory support, and mortality. Use of appropriate PPE, and supervised donning and doffing, are critical in avoiding cross infection from any AGP. Other factors, such as negative pressure rooms, high air exchange rates through the ventilation system, the ventilation system itself, and use of an anteroom, are additional important interventions to reduce the risks of cross infection. The use of HFNO for apnoeic oxygenation during laryngoscopy and tracheal intubation is recommended for selected patients with COVID-19 at high risk of hypoxaemia.15Wu C.N. Xia L.Z. Li K.H. et al.High-flow nasal-oxygenation-assisted fibreoptic tracheal intubation in critically ill patients with COVID-19 pneumonia: a prospective randomised controlled trial.Br J Anaesth. 2020; 125: e166-e168Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Another controversy associated with the use of HFNO is the concomitant use of a simple surgical mask as a means to minimise dispersion of aerosols in spontaneously breathing patients with COVID-19. A preliminary study using computational fluid dynamic simulation determined that addition of a surgical mask over a properly fitted HFNO device may be an effective option to reduce droplet deposition from exhaled gas flow.41Leonard S. Atwood Jr., C.W. Walsh B.K. et al.Preliminary findings on control of dispersion of aerosols and droplets during high-velocity nasal insufflation therapy using a simple surgical mask: implications for the high-flow nasal Cannula.Chest. 2020; 158: 1046-1049Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar A recent study of healthy volunteers evaluated aerosol production with HFNO and noninvasive positive pressure ventilation (NIPPV) compared with 6 L min−1 low-flow nasal oxygen (LFNO).35Miller D.C. Beamer P. Billheimer D. et al.Aerosol risk with noninvasive respiratory Support in patients with COVID-19.J Am Coll Emerg Physicians Open. 2020; 1: 521-526Crossref Google Scholar HFNO and LFNO were studied with and without subjects wearing a type 1 surgical face mask. Aerosol size and mass were measured at 2 and 6 ft from the patient's nasopharynx. There was no significant difference in aerosol production between HFNO, NIPPV, or LFNO. The use of a surgical mask over the HFNO device did not change aerosolised particle spread.35Miller D.C. Beamer P. Billheimer D. et al.Aerosol risk with noninvasive respiratory Support in patients with COVID-19.J Am Coll Emerg Physicians Open. 2020; 1: 521-526Crossref Google Scholar Further study is critical to confirm the safety and efficacy of the practice of applying a mask over HFNO devices. Barotrauma is a risk when HFNO is delivered simultaneously with a tightly sealed face mask, such as an anaesthesia face mask, owing to excessive delivered pressure, so this combination should be avoided.42Fisher & Paykel Healthcare. Optiflow thrive-optiflow oxygen kit AA400, optiflow filtered nasal cannula AA001M. Product information.Google Scholar There is currently no convincing evidence that HFNO increases the risk of COVID-19 cross infection to healthcare workers. Well-designed prospective studies are warranted to clarify the risk, if any, and to assess risk-reducing interventions. It is recommended that use of HFNO in patients with COVID-19 depends on the risk/benefit ratio determined by the clinician for each patient until additional information is available. Recent studies1Cook T.M. El-Boghdadly K. McGuire B. McNarry A.F. Patel A. Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists.Anaesthesia. 2020; 75: 785-799Crossref PubMed Scopus (570) Google Scholar,2Brewster D.J. Chrimes N. Do T.B. Fraser K. Groombridge C.J. Consensus statement: safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group.Med J Aust. 2020; 212: 472-481Crossref PubMed Scopus (249) Google Scholar,12Yao W. Wang T. Jiang B. et al.Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.Br J Anaesth. 2020; 125: e28-e37Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar,43Brown 3rd, C.A. Mosier J.M. Carlson J.N. Gibbs M.A. Pragmatic recommendations for intubating critically ill patients with suspected COVID-19.J Am Coll Emerg Physicians Open. 2020; 1: 80-84Crossref PubMed Google Scholar have recommended early tracheal intubation to minimise the risk of cross infection of healthcare workers. Early tracheal intubation may obviate the need for urgent intubation and may lessen the severity of hypoxaemia and haemodynamic instability during induction of anaesthesia and tracheal intubation. Results of the combined use of noninvasive respiratory support and awake prone positioning,44Coppo A. Bellani G. Winterton D. et al.Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study.Lancet Respir Med. 2020; 8: 765-774Abstract Full Text Full Text PDF PubMed Scopus (272) Google Scholar particularly in patients with the type L (high compliance) acute respiratory distress syndrome (ARDS), are encouraging.40Gattinoni L. Chiumello D. Caironi P. et al.COVID-19 pneumonia: different respiratory treatments for different phenotypes?.Intensive Care Med. 2020; 46: 1099-1102Crossref PubMed Scopus (1023) Google Scholar A recent report showed a significant decrease in the mortality rate of patients admitted to ICU with COVID-19. This is likely attributable to multiple factors, including increased clinical experience, rapidly developing management strategies and therapeutics and increased use of noninvasive ventilatory support such as HFNO.45Armstrong R.A. Kane A.D. 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Level III PPE appears to provide healthcare workers with maximum protection against cross infection by aerosolised SARS-CoV-2 viral particles. The highest level of PPE should be considered in the management of patients with COVID-19, especially during performance of AGPs. Global efforts should provide adequate levels of PPE for all healthcare workers during the pandemic and uniform application of environmental controls. Use of HFNO should be considered for management of acute respiratory failure and after tracheal extubation of patients with COVID-19 as long as optimal environmental measures and protective PPE are available for healthcare workers. Noninvasive ventilation is encouraged as the first-line approach before tracheal intubation and mechanical ventilation in critically ill patients with COVID-19 with the aforementioned caveats, although further study of this approach is warranted. All authors were involved in the conception and writing of manuscript HW is a consultant of Well Lead Medical Company, Guangzhou, Guangdong, China. PAB has received travel assistance and funding for research from Fisher and Paykel Healthcare. We thank David Gabrielsen (Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA) for his assistance with preparing Fig 1. We thank International Airway Management Society (IAMS) for organizing two virtual meetings contributing to the international expert consensus recommendations.