T he major challenges in managing patients with the
novel coronavirus disease (COVID-19) are bilateral pneumonia and acute respiratory distress syndrome. Many patients with COVID-19 will be in critical condition and will need intubation.1–4 Human-to-human transmission has been confirmed,5 and the virus has spread across the world. Based on current real-time reports, there are 78,962 con- firmed COVID-19 cases, with 7,952 patients still in critical Fig. 1. An intubation scene from Wuhan, China, the epicenter of condition as of February 28, 2020.6 Many have been intu- the COVID-19 battlefield provided by three of our team members who volunteered to travel from Shanghai and Qingdao to Wuhan to bated and many remain to be intubated.5 The problem is assist with patients there. From left to right: Rundong Tang, M.D. that the viral load in the airway is probably very high and is (anesthesiologist), Shumei Cao, M.D. (anesthesiologist), and Shu very contagious.3,4 This poses significant risks for these who Hong (nurse). As noted, all the individuals who are involved in the are performing intubation. intubation are wearing Level 3 protection. A video laryngoscope is Anesthesia providers play a vital role in providing used for rapid intubation and confirmation because the protective gear generates additional difficulty during the intubation. in-hospital intubation. However, they generally do not deal with patients with such highly contagious disease. The safety of the patient and the individuals who are involved in the intubation requires special consideration wet gauze to help prevent virus spreading. We believe that and precautions. Multiple articles related to the precau- muscle relaxants need to be used in such a situation. tions of intubation in the perioperative settings have Tracheal intubation should be performed by an experi- recently been published.7–9 Some are empirical recom- enced anesthesiologist with an experienced assistant (prefera- mendations from institutions outside of the epicenter bly also an anesthesiologist) and a nurse, to maximize patient of COVID-19. Here we present our updated first-hand safety (fig. 1) and to manage the severe hypoxemia and cir- experiences focusing on the safety of the patients and culatory failure that might occur. Muscle relaxants are highly providers performing intubation in an extreme situation recommended.5 The video laryngoscope should be placed as from the epicenter of COVID-19, Wuhan, China. As soon as muscle relaxation is achieved, and tracheal intubation shown in figure 1, three medical providers, who are vol- should be accomplished and confirmed as soon as possible unteers from Shanghai and Qingdao, traveled to Wuhan (less than 15 to 20 s). Confirming the depth of the endo- to assist with patients there. tracheal tube is extremely difficult using auscultation while wearing isolation suits. It is recommended instead to observe The Safety of the Patient bilateral chest expansion, ventilator breathing waveform, and respiratory parameters. End-tidal CO2 is a better indicator Patients with COVID-19 may experience myocardial injury of successful tracheal intubation, as oxygen saturation is not and multiple organ failure, which causes hemodynamic insta- always increased immediately after intubation in these patients, bility coinciding with low oxygen saturation. The patient’s because the oxygen exchange is significantly impaired. oxygen reserve is very poor, especially for those who are crit- Cricoid compression or displacement is needed when ically ill. This makes intubation a huge challenge. exposure of the cord is difficult and the patient’s fasting Based on our experience, rapid sequence induction is time is unknown; it is critical that suction is readily avail- recommended. To avoid virus scattering, assisted mask ven- able. Repeated tracheal intubation attempts could potentially tilation should be avoided. If positive mask ventilation is increase virus spread, so a laryngeal mask should be inserted needed based on clinical judgment, we recommended cov- after an intubation failure. Fogging of goggles is a serious ering the area around the patient’s mouth and nose with problem during rapid intubation, which can make intubation
and airway management a major challenge for the care pro- Research Support vider. Poor visibility also increases the risk for potential injury Support was provided solely from institutional and/or and infection. One solution to the problem of fogging may departmental sources. be to cover the inner side of the goggles with a layer of anti- fogging agent, such as transparent hand sanitizer. Competing Interests The Safety of the Care Providers The authors declare no competing interests. In a recent report related to 138 confirmed COVID-19 cases, 41.3% were considered acquired infection from the Mengqiang Luo, M.D., Shumei Cao, M.D., Liqun Wei, M.D., hospital, and more than 70% of these patients were health- Rundong Tang, M.D., Shu Hong, Renyu Liu, M.D., Ph.D., care providers.5 A high level of vigilance is necessary to Yingwei Wang, M.D., Ph.D. Huashan Hospital, Fudan prevent contracting the infection when intubation is per- University, Shanghai, China (R.L.). RenYu.Liu@pennmedicine. formed. Standard Level 3 protection5 should be worn by upenn.edu individuals performing the intubation, as shown in figure 1. DOI: 10.1097/ALN.0000000000003288 The recommended Level 3 protection process is as follows: hand disinfection → head cap → protective mask N95 1860 → surgical masks → isolation gown → disposable References latex gloves → goggles → protective clothing → disposable 1. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, Qiu latex gloves → shoe covers → disposable gown → dispos- Y, Wang J, Liu Y, Wei Y, Xia J, Yu T, Zhang X, Zhang able latex gloves → full head hood. Double masks with N95 L: Epidemiological and clinical characteristics of 99 1860 filter inside, gowns, and double gloves should be worn cases of 2019 novel coronavirus pneumonia in Wuhan, by the intubation team. The person who is performing the China: A descriptive study. Lancet 2020; 395:507-13 intubation should wear a third pair of gloves and remove 2. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang them immediately after intubation. L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Goggles and full protective headgear are necessary during Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, intubation, as shown in figure 1. A powered air-purifying Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, respirator system is recommended during the intubation of Cao B: Clinical features of patients infected with 2019 COVID-19 patients.The outer layer of the protective device novel coronavirus in Wuhan, China. Lancet 2020; is removed after direct patient contact and before touching 395:497-506 any equipment or furniture in other areas of the room; hand 3. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, Ren cleansing with disinfectant-containing alcohol is also neces- R, Leung KSM, Lau EHY, Wong JY, Xing X, Xiang sary. Endotracheal intubation guided by a video laryngoscope N, Wu Y, Li C, Chen Q, Li D, Liu T, Zhao J, Li M, Tu with a disposable cover is recommended. Fiber optic intuba- W, Chen C, Jin L, Yang R, Wang Q, Zhou S, Wang tion is feasible, but disinfection of the fibro bronchoscope sys- R, Liu H, Luo Y, Liu Y, Shao G, Li H, Tao Z, Yang Y, tem is inconvenient.The disposable cover should be removed Deng Z, Liu B, Ma Z, Zhang Y, Shi G, Lam TTY, Wu and exchanged for a new disposable protective device after each intubation before moving to the next patient who needs JTK, Gao GF, Cowling BJ, Yang B, Leung GM, Feng intubation.The contaminated instruments must not be taken Z: Early transmission dynamics in Wuhan, China, from the contaminated area to a clean area. They should be of novel coronavirus-infected pneumonia. N Engl discarded or disinfected following strict guidelines. Particular J Med 2020 [Epub ahead of print]. DOI: 10.1056/ care is necessary for the removal of potentially contaminated NEJMoa2001316 gloves, gowns, masks, and head covers; this contaminated 4. Tang JW,Tambyah PA, Hui DSC: Emergence of a novel clothing is disposed of as infectious materials. coronavirus causing respiratory illness from Wuhan, In the nonperioperative area, in the event of a diffi- China. J Infect 2020; 80:350–71 cult intubation, additional personnel and tools may not be 5. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang immediately available. A backup plan needs to be estab- B, Xiang H, Cheng Z, Xiong Y, Zhao Y, Li Y, Wang X, lished. A multidisciplinary “difficult away team” should be Peng Z: Clinical characteristics of 138 hospitalized established and readily available. We have a laryngeal mask patients with 2019 novel coronavirus-infected pneu- readily available. In the event of a failed intubation attempt, monia in Wuhan, China. JAMA 2020 [Epub ahead of a laryngeal mask should be used as a temporary bridging print]. DOI: 10.1001/jama.2020.1585 method. Under these circumstances a bedside tracheostomy 6. Real time dynamics of the COVID-19 in China, should be considered as early as possible. National Health Commission of the People’s Republic In conclusion, special consideration is needed to ensure of China, 2020 the highest safety when intubating patients who have 7. Chen X, Shang Y, Yao S, Liu R, Liu H: Perioperative COVID-19. care provider’s considerations in managing patients
with the COVID-19 Infections.Transl Perioper & Pain coronavirus (COVID-19). Anesthesia Patient Safety Med 2020; 7: 216-23 Foundation, February 12, 2020. Available at: https:// 8. Wax RS, Christian MD: Practical recommenda- www.apsf.org/news-updates/perioperative-consid- tions for critical care and anesthesiology teams caring erations-for-the-2019-novel-coronavirus-covid-19/. for novel coronavirus (2019-nCoV) patients. Can J Accessed March 13, 2020. Anaesth 2020 [Epub ahead of print]. DOI: 10.1007/ s12630-020-01591-x (Accepted for publication March 3, 2020.) 9. Zucco L, Levy N, Ketchandji D,Aziz M, Ramachandran SK: Perioperative considerations for the 2019 novel
Use of High-Flow Nasal Cannula Oxygen Therapy To Prevent Desaturation During Tracheal Intubation of Intensive Care Patients With Mild-to-Moderate Hypoxemia
