Pragmatic recommendations for intubating critically ill patients with suspected COVID-19.

Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated viral infection (coronavirus disease 2019, COVID-19) is a virulent, contagious viral pandemic that is affecting populations worldwide. As with any airborne viral respiratory infection, surgical and non-surgical patients may be affected. Methods: Review and synthesis of pertinent English-language literature pertaining to COVID-19 infection among adult patients. Results: COVID-19 disease that requires hospitalization results in critical illness approximately 25% of the time and requires mechanical ventilation with positive airway pressure. Acute kidney injury, a marked hypercoagulable state, and sometimes myocarditis can be features of COVID-19 in addition to the characteristic severe acute lung injury. Even if not among the most seriously afflicted, older patients with medical comorbidities are both predisposed to infection and risk increased morbidity and mortality, however, all persons presenting for surgical intervention should be suspected of infection (and thus transmissibility) even if asymptomatic. Although most elective surgery has been curtailed by administrative or governmental fiat, patients will still need urgent or emergency operative intervention for time-sensitive disease processes such as malignant neoplasia or for true emergencies such as perforated viscus or traumatic injury. It is possible to provide safe surgical care for SARS-CoV-2-positive patients and minimize nosocomial transmission to healthcare workers. Conclusions: This guidance will facilitate appropriate protection of patients and staff, and maintenance of infection control measures to assist surgical personnel and facilities to prepare for COVID-19-infected adult patients requiring urgent or emergent operative intervention and to provide optimal patient care.

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

I. Anaesthesia and SARS

Tracheotomy in Ventilated Patients With COVID-19.

Personal protective equipment has become an important and emotive subject during the current coronavirus disease 2019 epidemic. Coronavirus disease 2019 is predominantly caused by contact or droplet transmission attributed to relatively large respiratory particles which are subject to gravitational forces and travel only approximately 1 metre from the patient. Airborne transmission may occur if patient respiratory activity or medical procedures generate respiratory aerosols. These aerosols contain particles that may travel much longer distances and remain airborne longer, but their infective potential is uncertain. Contact, droplet and airborne transmission are each relevant during airway manoeuvres in infected patients, particularly during tracheal intubation. Personal protective equipment is an important component, but only one part, of a system protecting staff and other patients from coronavirus disease 2019 cross-infection. Appropriate use significantly reduces risk of viral transmission. Personal protective equipment should logically be matched to the potential mode of viral transmission occurring during patient care - contact, droplet or airborne. Recommendations from international organisations are broadly consistent, but equipment use is not. Only airborne precautions include a fitted high-filtration mask, and this should be reserved for aerosol generating procedures. Uncertainty remains around certain details of personal protective equipment including use of hoods, mask type and the potential for re-use of equipment.

Preoxygenation and Prevention of Desaturation During Emergency Airway Management

Anaesthetic management of patients with COVID-19: infection prevention and control measures in the operating theatre

The Importance of the Intubation Process for the Safety of Emergency Airway Management.

Role of Helmet-Delivered Noninvasive Pressure Support Ventilation in COVID-19 Patients

Introduction: Airway management is a critical skill for air medical providers, including the use of rapid sequence intubation (RSI) medications. Mediocre success rates and a high incidence of complications has challenged air medical providers to improve training and performance improvement efforts to improve clinical performance.Objectives: The aim of this research was to describe the experience with a novel, integrated advanced airway management program across a large air medical company and explore the impact of the program on improvement in RSI success.Methods: The Helicopter Advanced Resuscitation Training (HeART) program was implemented across 160 bases in 2015. The HeART program includes a novel conceptual framework based on thorough understanding of physiology, critical thinking using a novel algorithm, difficult airway predictive tools, training in the optimal use of specific airway techniques and devices, and integrated performance improvement efforts to address opportunities for improvement. The C-MAC video/direct laryngoscope and high-fidelity human patient simulation laboratories were implemented during the study period. Chi-square test for trend was used to evaluate for improvements in airway management and RSI success (overall intubation success, first-attempt success, first-attempt success without desaturation) over the 25-month study period following HeART implementation.Results: A total of 5,132 patients underwent RSI during the study period. Improvements in first-attempt intubation success (85% to 95%, p < 0.01) and first-attempt success without desaturation (84% to 94%, p < 0.01) were observed. Overall intubation success increased from 95% to 99% over the study period, but the trend was not statistically significant (p = 0.311).Conclusions: An integrated advanced airway management program was successful in improving RSI intubation performance in a large air medical company.

To the Editor We read with great interest the editorial by Dr Orser.1 We thank her for highlighting some critical concepts for clinicians dealing with the current coronavirus disease 2019 (COVID-19) crisis and congratulate her for the clarity and conciseness in delivering an important message. We would like to support her principles further with some considerations for clinicians. The first point is that COVID-19 appears to have a different clinical and epidemiological profile than severe acute respiratory syndrome (SARS). Despite being from similar coronavirus families, and the case fatality rate of SARS appears higher, the R0 of the SARS coronavirus 2 (SARS-CoV-2) that causes COVID-19 is greater. This results in a greater spread and a higher raw number of deaths.2 In Italy, the case fatality rate has been high, with 16,654 deaths out of 136,110 positive cases as of April 9, 2020, with health care professionals being at highest risk for infection, accounting for around 10% of positive cases (Istituto Superiore di Sanità; https://www.epicentro.iss.it/coronavirus/sars-cov-2-sorveglianza-dati). The transmissibility of SARS-CoV-2 might have been underestimated by many. In Italy, there is a high rate of health care worker–related infection leading to self-isolation, hospitalization, and critical care admission, with its consequences on health care delivery and the well-being of the workforce. One of the key concerns with the SARS-CoV-2 virus is that the modality for transmission remains uncertain, as "airborne diffusion cannot be ruled out at this stage."3 Compounding this uncertainty is the potential for the virus to variably survive on different surfaces and a lack of vaccine or specific treatment.2 There are some suggestions that the virus should be treated on bio-safety level 4,4 which is obviously not feasible in pandemic settings. However, we advocate maximizing the level of personal protective equipment (PPE) during aerosol-generating procedures (AGPs), such as tracheal intubation and noninvasive ventilation and high-flow nasal oxygen use.2 The use of N95 respirators, which offers a similar degree of protection as filtering face piece (FFP)2 respirators,2 with some data suggesting that they are in fact equivalent to surgical facemasks.5 Recommendations in Italy2 and the United Kingdom6 are for the use of FFP3 or N99 masks, which is different from North American recommendations. Ideally, powered air-purifying respirators (PAPRs) should be used.2,4 Additionally, we advocate the use of goggles, a visor/face shield, double (or triple) gloving, and ideally a full body suit. We completely agree with Dr Orser's1 recommendations for training in PPE donning and doffing, harnessing teamwork, and leadership by the most expert airway manager. Further, we also highlight the importance of planning (communication in PPE could be particularly challenging) and of hemodynamic optimization, if time is available. We strongly advocate for the conduct of rapid sequence intubation with full-dose neuromuscular blockade to minimize the risk of coughing and the use of videolaryngoscopy, possibly with separate screen, as well as using a preloaded bougie or stylet as routine adjunct to maximize first-pass success.2 Any AGP should be avoided, ideally including mask ventilation. Unfortunately, hypoxemia is a hallmark of COVID-19 patients requiring tracheal intubation, and patients do not tolerate the cessation of oxygen supplementation or apnea well. Conventional preoxygenation might be difficult and relatively ineffective; thus, we usually discontinue already ongoing noninvasive ventilation or continuous positive airway pressure (CPAP), turning the ventilator off and slowly removing facemask starting from the inferior edge (toward the patient's feet) to depressurize the circuit before proceeding with tracheal intubation. Should ventilation be needed, we advocate that it should be gently provided with Mapleson C (Waters; Covidien, Mirandola, Italy) circuit with a double filter setting (Figure). Despite the time-critical nature of airway management in critically ill patients with COVID-19, we recommend a rapid airway assessment be performed allowing for early planning of airway management to avoid unexpected deterioration and clinical decision making.2Figure.: Mapleson C (Waters) circuit with a double filter setting to prevent aerosolization during facemask ventilation of COVID-19 patients. COVID-19 indicates coronavirus disease 2019.Overall, we applaud Dr Orser's1 recommendations, and also wish to highlight that health care providers should be protected to maximum available level, while still taking account of ongoing global PPE shortage.2 Prioritization of clinicians involved in high-risk AGPs is crucial for the sustainability in delivering health care during this pandemic. We need to be well prepared to enter the den of the beast. Massimiliano Sorbello, MDDepartment of EmergencyAnesthesia and Intensive CareAzienda Ospedaliero Universitaria (AOU) Policlinico San Marco University HospitalCatania, Italy[email protected] Kariem El-Boghdadly, MDDepartment of AnaesthesiaGuy's and St Thomas' National Health System (NHS) Foundation TrustLondon, United Kingdom Flavia Petrini, MDAnesthesia and Intensive Care Dipartimento di Medicina PerioperatoriaDolore, Terapia Intensiva e Rapid Response System, Ospedale di Chieti, Università "G. D'Annunzio"Chieti-Pescara, Italy

The effect of severe acute respiratory syndrome (SARS) on emergency airway management

Walking the line between benefit and harm from tracheostomy in COVID-19

Exhaled Air and Aerosolized Droplet Dispersion During Application of a Jet Nebulizer

Trends in personal protective equipment use by clinicians performing airway procedures for patients with coronavirus disease 2019 in the USA from the intubateCOVID registry