Review Article

Emerging Perspectives of Endotracheal Intubation in Patients with Severe COVID- 19 Pneumonia: A Narrative Review

Abstract

The coronavirus disease 2019 (COVID -19) pandemic that has engulfed the world has put an immense strain on the existing healthcare systems. The rapid, insidious and often dramatic deterioration of the respiratory function of an infected patient, has led to an increased need for effective and rapid airway control. However, such airway control techniques put the healthcare workers to an increased risk of exposure to the virus. Therefore, interventions aimed at minimising such risks, while preventing the complications inherent to securing an airway are imperative to the management of a COVID-19 patient in acute respiratory failure (ARF). Personal protective equipment (PPE) is sine qua non to keep the intubator safe, however some barrier equipment’s have been employed with limited success. There are varied schools of thought on whether to intubate early or late, and the use of non-invasive methods for management of respiratory failure, however, most consensus statements reinforce the need for rapid sequence induction (RSI), which provides ideal intubating environment for an experienced intubator. Techniques, which decrease the number of required personnel as well as time, to secure the airway and increase the distance of the intubating physician from the patient, are recommended. Routine use of, videolaryngoscope, if available, is recommended. While intubation with an endotracheal tube is the gold standard airway technique, second generation supraglottic airway devices (SAD) are increasingly being recommended, particularly in cases of failure to intubate or in an unanticipated difficult airway. Awake intubation techniques are contraindicated due to increased risk of cough and subsequent aerosolization; however, few modifications were innovated when if it all required. In this review, we summarise the existing data with respect to the modifications and guidelines in severe COVID-19 patients who requires endotracheal intubation for invasive mechanical ventilatory support.

[1] Tang LY, Wang J. Anesthesia and COVID-19: What We Should Know and What We Should Do. Semin Cardiothorac Vasc Anesth. 2020; 24(2):127-37.
[2] Szarpak L, Drozd A, Smereka J. Airway management and ventilation principles in COVID-19 patients. J Clin Anesth. 2020; 65:109877.
[3] Weissman D, de Perio M, Radonovich L. COVID-19 and Risks Posed to Personnel During Endotracheal Intubation. JAMA. 2020; 323:2027.
[4] Brewster D, Chrimes N, Do T, Fraser K, Groombridge C, Higgs A, et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID ‐19 adult patient group. Med J Aust. 2020; 212:472-81.
[5] Chahar P, Dugar S, Marciniak D. Airway management considerations in patients with COVID-19. Cleve Clin J Med. 2020.
[6] Hur K, Price C, Gray E, Gulati R, Maksimoski M, Racette S et al. Factors Associated With Intubation and Prolonged Intubation in Hospitalized Patients With COVID-19. Otolaryngol Head Neck Surg. 2020; 163:170-8.
[7] Wong P, Lim W. Aligning difficult airway guidelines with the anesthetic COVID-19 guidelines to develop a COVID-19 difficult airway strategy: a narrative review. J Anesth. 2020; 34:924-43.
[8] Trembley L, Tobias A, Schillo G, Foerster N, Singer J, Pavelka S et al. A Multidisciplinary Intubation Algorithm for Suspected COVID-19 Patients in the Emergency Department. Western Journal of Emergency Medicine. 2020; 21(4):764-70.
[9] Sullivan E, Gibson L, Berra L, Chang M, Bittner E. In-hospital airway management of COVID-19 patients. Crit Care. 2020; 24(1):292.
[10] Meng L, Qiu H, Wan L, Ai Y, Xue Z, Guo Q, et al. Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan’s Experience. Anesthesiology. 2020; 132:1317–32.
[11] Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D. COVID-19 Does Not Lead to a “Typical” Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2020; 201:1299–300.
[12] Gattinoni L, Chiumello D, Rossi S. COVID-19 pneumonia: ARDS or not? Crit Care. 2020; 24(1):154.
[13] Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med. 2020; 46:1099–102.
[14] Zhang L, Li J, Zhou M, Chen Z. Summary of 20 tracheal intubation by anesthesiologists for patients with severe COVID-19 pneumonia: retrospective case series. J Anesth. 2020; 34:599-606.
[15] Tobin MJ, Laghi F, Jubran A. Caution about early intubation and mechanical ventilation in COVID-19. Ann Intensive Care. 2020; 10:78.
[16] Verdiner RE, Choukalas CG, Siddiqui S, Stahl DL, Galvagno SM, Jabaley CS, et al. COVID–Activated Emergency Scaling of Anesthesiology Responsibilities Intensive Care Unit. Anesth Analg. 2020; 131:365–77.
[17] Miller L, Luković E, Wagener G. Guiding airway management and personal protective equipment for COVID-19 intubation teams. Br J Anaesth. 2020; 125: e288–90.
[18] Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier Enclosure during Endotracheal Intubation. N Engl J Med. 2020; 382:1957–8.
[19] Aletreby WT, Alharthy AM, Madi AF, Ramadan OE, Alodat MA, Huwait BM, et al. Impact of Aerosol Box on Duration of Intubation of COVID-19 Patients: Simulation Cross-over Study. International Journal of Health Sciences and Research. 2020; 10:22-7.
[20] Vijayaraghavan S, Puthenveettil N. Aerosol box for protection during airway manipulation in covid-19 patients. Indian J Anaesth. 2020; 64:S148-9
[21] Kinjo S, Dudley M, Sakai N. Modified Wake Forest Type Protective Shield for an Asymptomatic, COVID-19 Nonconfirmed Patient for Intubation Undergoing Urgent Surgery. Anesth Analg. 2020; 131: e127-8.
[22] Rahmoune FC, Ben Yahia MM, Hajjej R, Pic S, Chatti K. Protective Device during Airway Management in Patients with Coronavirus Disease 2019 (COVID-19). Anesthesiology. 2020; 133:473–5.
[23] Osorio-Fonseca E, Blanco H, Alvernia JE. Letter to the Editor New Design for Aerosol Protection During Endotracheal Intubation in the Coronavirus Disease 2019 (COVID-19) Pandemic Era: The “Anti-Aerosol Igloo” (AAI). World Neurosurg. 2020; 139:720–2.
[24] Chen C, Shen N, Li X, Zhang Q, Hei Z. New device and technique to protect intubation operators against COVID-19. Intensive Care Med. 2020; 46:1627–9.
[25] Cook TM, El-Boghdadly K, McGuire B, McNarry AF, 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; 75:785-99
[26] Patwa A, Shah A, Garg R, Divatia J, Kundra P, Doctor J, et al. All India difficult airway association (AIDAA) consensus guidelines for airway management in the operating room during the COVID-19 pandemic. Indian J Anaesth. 2020; 64:107-15
[27] Brown CA 3rd, Mosier JM, Carlson JN, Gibbs MA. Pragmatic recommendations for intubating critically ill patients with suspected COVID-19. J Am Coll Emerg Physicians Open. 2020; 1:80–4
[28] Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth. 2020; 67:568–76.
[29] Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012; 59:165-75. e1.
[30] Sorbello M, El-Boghdadly K, Di Giacinto I, Cataldo R, Esposito C, Falcetta S, Merli G, Cortese G, Corso RM, Bressan F, Pintaudi S, Greif R, Donati A, Petrini F; Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) Airway Research Group, and The European Airway Management Society. The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice. Anaesthesia. 2020; 75:724-32
[31] De Jong A, Pardo E, Rolle A, Bodin-Lario S, Pouzeratte Y, Jaber S. Airway management for COVID-19: a move towards universal videolaryngoscope? The Lancet Respir Med. 2020; 8:555
[32] Arulkumaran N, Lowe J, Ions R, Mendoza M, Bennett V, Dunser MW. Video laryngoscopy versus direct laryngoscopy for emergency orotracheal intubation outside the operating room: a systematic review and meta-analysis. Br J Anaesth 2018; 120:712–24.
[33] Zeidan A, Bamadhaj M, Al-Faraidy M, Ali M. Videolaryngoscopy Intubation in Patients with COVID-19: How to Minimize Risk of Aerosolization? Anesthesiology. 2020; 133:481–3
[34] Wong J, Ong S, Ang LS. Intubation of the patient with a suspected or confirmed COVID-19 infection. Trends in Anaesthesia and Critical Care. 2020; 33:25–6.
[35] Luo M, Cao S, Wei L, Tang R, Hong S, Liu R, et al. Precautions for Intubating Patients with COVID-19. Anesthesiology. 2020; 132:1616–8.
[36] Matava CT, Kovatsis PG, Lee JK, Castro P, Denning S, Yu J, et al. Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia’s Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society. Anesth Analg. 2020; 131:61–73.
[37] Endersby RVW, Ho ECY, Schubert E, Spencer AO. Modified tracheal extubation for patients with COVID-19. Br J Anaesth. 2020;125: e191–2.
[38] Yang W-S, Hou S-W, Lee B-C, Chiang W-C, Chien Y-C, Chen S-Y, et al. Taipei Azalea – Supraglottic airways (SGA) preassembled with high-efficiency particulate air (HEPA) filters to simplify prehospital airway management for patients with out-of-hospital cardiac arrests (OHCA) during Coronavirus Disease 2019 (COVID-19) pandemic. Resuscitation. 2020; 151:3–5.
[39] Chua H, Lim WY, Mok M, Wong P. "Closed" Supraglottic Airway-Guided Intubation During the COVID-19 Pandemic: A Glo Germ Follow-up. Anesth Analg. 2020; 131:e168-9.
Files
IssueVol 7 No 2 (2021): Spring QRcode
SectionReview Article(s)
Published2021-05-31
DOI https://doi.org/10.18502/aacc.v7i2.6303
Keywords
COVID-19 Endotracheal Intubation ARDS Supraglottic Airway Device Videolaryngoscope Aerosols Mechanical ventilation

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
1.
Kapoor D, Atter P, Kang A, Singh M. Emerging Perspectives of Endotracheal Intubation in Patients with Severe COVID- 19 Pneumonia: A Narrative Review. Arch Anesth & Crit Care. 7(2):96-02.