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Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.

ABSTRACT: Tracheal intubation in coronavirus disease 2019 (COVID-19) patients creates a risk to physiologically compromised patients and to attending healthcare providers. Clinical information on airway management and expert recommendations in these patients are urgently needed. By analysing a two-centre retrospective observational case series from Wuhan, China, a panel of international airway management experts discussed the results and formulated consensus recommendations for the management of tracheal intubation in COVID-19 patients. Of 202 COVID-19 patients undergoing emergency tracheal intubation, most were males (n=136; 67.3%) and aged 65 yr or more (n=128; 63.4%). Most patients (n=152; 75.2%) were hypoxaemic (Sao2 <90%) before intubation. Personal protective equipment was worn by all intubating healthcare workers. Rapid sequence induction (RSI) or modified RSI was used with an intubation success rate of 89.1% on the first attempt and 100% overall. Hypoxaemia (Sao2 <90%) was common during intubation (n=148; 73.3%). Hypotension (arterial pressure <90/60 mm Hg) occurred in 36 (17.8%) patients during and 45 (22.3%) after intubation with cardiac arrest in four (2.0%). Pneumothorax occurred in 12 (5.9%) patients and death within 24 h in 21 (10.4%). Up to 14 days post-procedure, there was no evidence of cross infection in the anaesthesiologists who intubated the COVID-19 patients. Based on clinical information and expert recommendation, we propose detailed planning, strategy, and methods for tracheal intubation in COVID-19 patients.

SUBMITTER: Yao W

PROVIDER: S-EPMC7151238 | biostudies-literature | 2020 Jul

REPOSITORIES: biostudies-literature

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Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.

Yao Wenlong W Wang Tingting T Jiang Bailin B Gao Feng F Wang Li L Zheng Hongbo H Xiao Weimin W Yao Shanglong S Mei Wei W Chen Xiangdong X Luo Ailin A Sun Liang L Cook Tim T Behringer Elizabeth E Huitink Johannes M JM Wong David T DT Lane-Fall Meghan M McNarry Alistair F AF McGuire Barry B Higgs Andrew A Shah Amit A Patel Anil A Zuo Mingzhang M Ma Wuhua W Xue Zhanggang Z Zhang Li-Ming LM Li Wenxian W Wang Yong Y Hagberg Carin C O'Sullivan Ellen P EP Fleisher Lee A LA Wei Huafeng H

British journal of anaesthesia 20200410 1

Tracheal intubation in coronavirus disease 2019 (COVID-19) patients creates a risk to physiologically compromised patients and to attending healthcare providers. Clinical information on airway management and expert recommendations in these patients are urgently needed. By analysing a two-centre retrospective observational case series from Wuhan, China, a panel of international airway management experts discussed the results and formulated consensus recommendations for the management of tracheal ...[more]

PMID: 32312571

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Project description:IntroductionPre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety.MethodsWe conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene.ResultsFrom 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P=0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P=0.047).ConclusionsThis comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.

Project description:BackgroundTracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative.MethodsWe conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider's level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy.ResultsFPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers' expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations (p < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified.ConclusionAirway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.

Project description:BackgroundRecommendations to prevent morbidity and mortality in children was a high priority for the editorial group of a WHO pocket book for primary health care in the European region. However, the benefit of preventive interventions is not always clear and recommendations differ across countries and institutions. Here, we summarize the existing recommendations and the most recent evidence on ten selected preventive interventions applied to children under five years to inform this group. In addition, we reflect on the process and challenges of developing these summaries.MethodsFor each intervention, we systematically searched for current recommendations from the WHO, the United States Preventive Services Task Force, the workgroup PrevInfad from the Spanish Association of Primary Care Pediatrics, the Centers of Disease Control and Prevention, and the National Institute for Health and Care Excellence. Then, we systematically searched the sources above and the Cochrane library for relevant systematic reviews. For each topic, we reported the recommendations and the strength of the recommendation when and as reported by the authors. We summarized the main findings of systematic reviews with the certainty of the evidence as reported. Categorising the ten preventive interventions in three groups allowed narrative comparisons between similar types of interventions and between groups.Results and discussionFor the single interventions of providing vitamins D and K and topical fluoride there is overall a high degree of consensus between institutions for the evidence of their effectiveness. For the multiple interventions to prevent sudden infant death syndrome and unintentional injuries consensus was more variable as evidence of effectiveness is harder to ascertain. For the screening interventions the summaries of recommendations and evidence varied too. While institutions generally agreed in recommending for vision screening and against universal screening for language and speech delay and iron deficiency, they had some differences for pulse oximetry and autism. The transparent and independent process shed light upon how institutions use existing evidence in their settings - common and different positions were accounted for and became visible. We also identified gaps and duplications of research. Our approach was a crucial starting point for developing the respective sections in the pocket book.

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Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.

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Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.

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