Guiding airway management and personal protective equipment for COVID-19 intubation teams

      Keywords

      Editor—Tracheal intubation of patients with coronavirus disease-19 (COVID-19) is a potentially aerosol-generating procedure that requires a careful yet efficient approach to ensure the safety of both patients and healthcare providers.
      Centers for Disease Control and Prevention
      Healthcare infection prevention and control FAQs for COVID-19.
      Faced with a rapidly escalating number of cases in New York City, the epicentre of the COVID-19 outbreak in the USA, our institution quickly created guidelines for the airway management of COVID-19 patients and an infrastructure to provide sufficient personal protective equipment (PPE) for intubating teams. Careful planning developing processes to ensure that PPE is readily available, creating standardised airway management protocols, and simulations and training of staff are crucial to ensure the safety of patients and healthcare workers.

      Ensuring access to PPE

      We developed an institutional protocol for use of PPE for intubations and a system to ensure our intubating teams had adequate supply. Our goal was to prevent situations in which providers had to choose between their safety and their ability to save patients' lives because adequate PPE was not readily available. With this in mind, we created ‘COVID-19 bags’ (Table 1) containing sufficient PPE for two providers to bring to intubations. Our goals were for PPE to (i) be easily transported by intubating teams, (ii) carry a low risk of self-contamination during doffing, and (iii) be in accordance with the Centers for Disease Control and Prevention PPE recommendations for aerosol-generating procedures in COVID-19 patients.
      Centers for Disease Control and Prevention
      Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings.
      Table 1COVID-2019 bag inventory. ∗For double-gloving, we recommend one pair of sterile surgical gloves because their longer cuffs provide better wrist protection. The top layer should be removed immediately after intubation. Placed on the expiratory limb of a ventilator or between the tracheal tube and self-inflating bag. After the McGrath® (Medtronic, Minneapolis, MN, USA) videolaryngoscope handle is cleaned with bleach or alcohol-based wipes, it is handed to an assistant outside of the patient room, cleaned again, and placed in a plastic bag.
      N95 mask respirators: Regular and small sizes
      Disposable waterproof gowns for intubating provider and airway assistant
      Disposable non-waterproof gowns for providers not directly involved in airway management
      Head covering: bouffant or head/neck wrap
      Eye/face protection: welder-style face mask or surgical mask with face shield attached
      Sterile surgical gloves∗
      High-efficiency particulate air (HEPA) filter
      Small plastic bags

      Guidelines for tracheal intubation

      Our guidelines are based on reports from the severe acute respiratory syndrome coronavirus 1 outbreak and recommendations from the Anesthesia Patient Safety Foundation.
      • Lapinsky S.E.
      • Granton J.T.
      Critical care lessons from severe acute respiratory syndrome.
      • Kamming D.
      • Gardam M.
      • Chung F.
      Anaesthesia and SARS.
      • Peng P.W.H.
      • Ho P.-L.
      • Hota S.S.
      Outbreak of a new coronavirus: what anaesthetists should know.
      The main objective is to reduce the risk of aerosolisation during intubation by.
      • (i)
        rapid sequence intubation and avoidance of bag-mask ventilation, if possible;
      • (ii)
        use of videolaryngoscopy to increase the distance from the patient's airway and the chance of success during first attempt;
      • (iii)
        immediate inflation of the tracheal tube cuff and connection to the ventilatory circuit, thereby avoiding manual ventilation;
      • (iv)
        use of a high-efficiency particulate air filter placed on the expiratory limb of a ventilator, or between the tracheal tube and a self-inflating bag ventilator;
      • (v)
        intubation in a negative-pressure room, or, if not available, a single room with closed doors. Of note, we did not use Plexiglass ‘intubation boxes’
        • Canelli R.
        • Connor C.W.
        • Gonzalez M.
        • Nozari A.
        • Ortega R.
        Barrier enclosure during endotracheal intubation.
        as they are difficult to transport and limit mobility during intubation without necessarily providing superior protection compared with videolaryngoscopy.
        • Gould C.L.
        • Alexander P.D.G.
        • Allen C.N.
        • McGrath B.A.
        • Shelton C.L.
        Protecting staff and patients during airway management in the COVID-19 pandemic: are intubation boxes safe?.

      Intubation teams

      At the beginning of the COVID-19 crisis, the anaesthesiology department created intubation teams that performed all intubations in the hospital. The team consisted of an attending anaesthesiologist and two residents. The most experienced provider performed the intubation, and the next most experienced provider administered medications, monitored vital signs, and assisted with the intubation. The most junior member remained outside the room to provide additional supplies if needed and monitor for breaches in PPE. Before entering the room, we performed a huddle with the patient's medical team, nurse, and respiratory therapist to review medical history, procedural steps for intubation, and contingency plans.

      Training providers

      In addition to wide distribution of the airway management protocol through e-mails, fliers, and grand rounds, we created a simulation video demonstrating PPE donning and doffing and intubation sequence. We also held PPE donning and doffing training sessions in the simulation centre using mock PPE for residents and faculty.
      From March 11 to May 4, 2020, we performed 446 intubations with a peak of 32 intubations on April 8. During the height of the crisis, two intubation teams were on call at all times. The well-established airway management guidelines and COVID-19 bags allowed the intubation teams to perform a rapidly escalating number of tracheal intubations efficiently and safely.

      Challenges and solutions

      • (i)
        Ensuring adequate sedation post-intubation: A substantial number of patients in non-ICU settings self-extubated shortly after intubation. In response, the department developed a sedation protocol that included administration of a midazolam bolus and initiation of a propofol infusion immediately after intubation.
      • (ii) Post-intubation haemodynamic instability: Our surgery colleagues created procedure teams that rapidly placed arterial and central lines for monitoring and infusions of vasoactive drugs after intubation
        • Coons B.E.
        • Tam S.F.
        • Okochi S.
        Rapid development of resident-led procedural response teams to support patient care during the coronavirus disease 2019 epidemic: a surgical workforce activation team.
        .
      • (iii) Restocking supplies as demand escalates: At the beginning of the crisis, we purchased our own bags and stocked them using supplies from the operating theatre and the ICUs. When the number of intubations escalated rapidly, the hospital created a supply chain for ordering supplies and assembling the COVID-19 bags.
      We strongly recommend that hospitals create a plan to ensure their intubation teams have access to appropriate PPE and airway protocols for COVID-19 patients before a crisis develops. Our airway management guidelines and COVID-19 bags were invaluable as the number of intubations rapidly accelerated. Importantly, hospitals must be prepared to modify their airway management and PPE guidelines based on feedback from clinicians on the ground and improved understanding of the transmissibility of the virus.

      Declarations of interest

      The authors have no conflicts of interest to declare.

      References

        • Centers for Disease Control and Prevention
        Healthcare infection prevention and control FAQs for COVID-19.
        2020 (Available from:)
        • Centers for Disease Control and Prevention
        Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings.
        2020 (Available from:)
        • Lapinsky S.E.
        • Granton J.T.
        Critical care lessons from severe acute respiratory syndrome.
        Curr Opin Crit Care. 2004; 10: 53-58
        • Kamming D.
        • Gardam M.
        • Chung F.
        Anaesthesia and SARS.
        Br J Anaesth. 2003; 90: 715-718
        • Peng P.W.H.
        • Ho P.-L.
        • Hota S.S.
        Outbreak of a new coronavirus: what anaesthetists should know.
        Br J Anaesth. 2020; 124: 497-501
        • Canelli R.
        • Connor C.W.
        • Gonzalez M.
        • Nozari A.
        • Ortega R.
        Barrier enclosure during endotracheal intubation.
        N Engl J Med. 2020; 382: 1957-1958
        • Gould C.L.
        • Alexander P.D.G.
        • Allen C.N.
        • McGrath B.A.
        • Shelton C.L.
        Protecting staff and patients during airway management in the COVID-19 pandemic: are intubation boxes safe?.
        Br J Anaesth. 2020; 125: e294-e295
        • Coons B.E.
        • Tam S.F.
        • Okochi S.
        Rapid development of resident-led procedural response teams to support patient care during the coronavirus disease 2019 epidemic: a surgical workforce activation team.
        JAMA Surg. 2020; https://doi.org/10.1001/jamasurg.2020.1782