Development of an emergency airway response system for COVID-19 at a tertiary care hospital in resource limited country.

The ongoing coronavirus (COVID-19) infection causes severe respiratory dysfunction and has become an emergent issue for worldwide healthcare due to highly transmissible and contagious nature. Aerosol generating procedures such as tracheal intubation is of particularly high risk. This mandates some advice on processes and techniques required to protect staff and uniform approach during airway management. We hereby share our experience in development of an emergency response system to deal with COVID airway management at a frontline hospital which particularly consider the local demands and resources. This includes a change in working dynamics with 24/7 consultant coverage for emergent or urgent tracheal intubation of COVID patients at non-operating room locations. Other steps include prepackaging intubation baskets, availability of videolaryngoscope, standard personal protective equipment including powered air purifying respirator, and use of modified intubation checklist.

Head and neck cancer recurrence with limited mouth opening, radiation fibrosis and confirmed COVID-19 infection: Approach to airway management.

We present a case that describes the airway management of a patient with recurrent head and neck cancer and confirmed COVID-19 infection. Securing airway of these patients with anticipated difficulty and at the same time limiting virus exposure to providers can be challenging. The risk of aerosolization during awake tracheal intubation is extreme as it carries a high risk of transmitting respiratory infections. A multidisciplinary team discussion before the procedure highlighted aspects of both airway management and the urgency of surgical procedure where particular care and modifications are required. Successful flexible bronchoscopy and intubation was done under inhalational anaesthetics with spontaneous breathing. Although fiberoptic intubation during sleep,in anticipated difficult airways, have led to enhanced intubation time, this technique was opted to minimize the risk of aerosol generation associated with topicalisation, coughing and hence reduced incidence of cross infection to health care workers.

A Survey of Current Practices and Adherence to Coronavirus Disease Airway Management Guidelines Among Frontline Healthcare Professionals in a Resource-Limited Country.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) has brought anaesthesiologists, intensive care and emergency physicians to the forefront due to their airway management skills. The aim of survey was to determine current practice trends in COVID-19 airway management among frontline healthcare professionals of Pakistan and their adherence to standard principles proposed by most consensus guidelines. METHODS: An online questionnaire was designed based on consensus guidelines from international societies. We contacted consultants and trainees nationwide working in anaesthesia, intensive care, and emergency departments through emails, phone calls, and social media platforms. RESULTS: A total of 285 individuals participated in this cross-sectional descriptive study. Intubations were largely performed by anaesthetists followed by emergency physicians. Deteriorating respiratory failure (89%) was the most frequent indication. Availability of trained staff, use of intubation checklist, limited staff presence during intubation, and use of appropriate personal protective equipment were positive findings. One-third reported that their workplace did not have negative pressure rooms for aerosol-generating procedures, and 63.3% responders do not perform airway assessment before intubation. The device of choice for the first attempt at laryngoscopy was Macintosh laryngoscope (51.6%) followed by videolaryngoscopes with disposable blades (24.2%). Availability of rescue devices in case of unanticipated difficult airway is variable; laryngeal mask airway (70.1%), bougie (82.2%), and stylet (68.7%) were present at majority places. Frequency of airway-related adverse events including hypoxemia (69.8%) and failed first attempt intubation (35.2%) was significant. CONCLUSION: This survey found satisfactory knowledge, comparable practices, and offers some important insights about airway management in COVID-19 patients by healthcare professionals of Pakistan.

Emergency Airway Management in Patients with COVID-19: A Prospective International Multicenter Cohort Study.

BACKGROUND: Tracheal intubation for patients with COVID-19 is required for invasive mechanical ventilation. The authors sought to describe practice for emergency intubation, estimate success rates and complications, and determine variation in practice and outcomes between high-income and low- and middle-income countries. The authors hypothesized that successful emergency airway management in patients with COVID-19 is associated with geographical and procedural factors. METHODS: The authors performed a prospective observational cohort study between March 23, 2020, and October 24, 2020, which included 4,476 episodes of emergency tracheal intubation performed by 1,722 clinicians from 607 institutions across 32 countries in patients with suspected or confirmed COVID-19 requiring mechanical ventilation. The authors investigated associations between intubation and operator characteristics, and the primary outcome of first-attempt success. RESULTS: Successful first-attempt tracheal intubation was achieved in 4,017/4,476 (89.7%) episodes, while 23 of 4,476 (0.5%) episodes required four or more attempts. Ten emergency surgical airways were reported-an approximate incidence of 1 in 450 (10 of 4,476). Failed intubation (defined as emergency surgical airway, four or more attempts, or a supraglottic airway as the final device) occurred in approximately 1 of 120 episodes (36 of 4,476). Successful first attempt was more likely during rapid sequence induction versus non-rapid sequence induction (adjusted odds ratio, 1.89 [95% CI, 1.49 to 2.39]; P < 0.001), when operators used powered air-purifying respirators versus nonpowered respirators (adjusted odds ratio, 1.60 [95% CI, 1.16 to 2.20]; P = 0.006), and when performed by operators with more COVID-19 intubations recorded (adjusted odds ratio, 1.03 for each additional previous intubation [95% CI, 1.01 to 1.06]; P = 0.015). Intubations performed in low- or middle-income countries were less likely to be successful at first attempt than in high-income countries (adjusted odds ratio, 0.57 [95% CI, 0.41 to 0.79]; P = 0.001). CONCLUSIONS: The authors report rates of failed tracheal intubation and emergency surgical airway in patients with COVID-19 requiring emergency airway management, and identified factors associated with increased success. Risks of tracheal intubation failure and success should be considered when managing COVID-19.