Comparison of Vie Scope® and Macintosh laryngoscopes for intubation during resuscitation by paramedics wearing personal protective equipment.

BACKGROUND: Endotracheal intubation (ETI) is still the gold standard of airway management, but in cases of sudden cardiac arrest in patients with suspected SARS-CoV-2 infection, ETI is associated with risks for both the patient and the medical personnel. We hypothesized that the Vie Scope® is more useful for endotracheal intubation of suspected or confirmed COVID-19 cardiac arrest patients than the conventional laryngoscope with Macintosh blade when operators are wearing personal protective equipment (PPE). METHODS: Study was designed as a prospective, multicenter, randomized clinical trial performed by Emergency Medical Services in Poland. Patients with suspected or confirmed COVID-19 diagnosis who needed cardiopulmonary resuscitation in prehospital setting were included. Patients under 18 years old or with criteria predictive of impossible intubation under direct laryngoscopy, were excluded. Patients were randomly allocated 1:1 to Vie Scope® versus direct laryngoscopy with a Macintosh blade. Study groups were compared on success of intubation attempts, time to intubation, glottis visualization and number of optimization maneuvers. RESULTS: We enrolled 90 out-of-hospital cardiac arrest (OHCA) patients, aged 43-92 years. Compared to the VieScope® laryngoscope, use of the Macintosh laryngoscope required longer times for tracheal intubation with an estimated mean difference of -48 s (95%CI confidence interval [CI], -60.23, -35.77; p < 0.001). Moreover VieScope® improved first attempt success rate, 93.3% vs. 51.1% respectively (odds ratio [OR] = 13.39; 95%CI: 3.62, 49.58; p < 0.001). CONCLUSIONS: The use of the Vie Scope® laryngoscope in OHCA patients improved the first attempt success rate, and reduced intubation time compared to Macintosh laryngoscope in paramedics wearing PPE for against aerosol generating procedures. TRIAL REGISTRATION: ClinicalTrials registration number NCT04365608.

Unintended consequences: The impact of airway management modifications introduced in response to COVID-19 on intubations in a tertiary centre emergency department.

OBJECTIVE: In response to COVID-19, we introduced and examined the effect of a raft of modifications to standard practice on adverse events and first-attempt success (FAS) associated with ED intubation. METHODS: An analysis of prospectively collected registry data of all ED intubations over a 3-year period at an Australian Major Trauma Centre. During the first 6 months of the COVID-19 pandemic in Australia, we introduced modifications to standard practice to reduce the risk to staff including: aerosolisation reduction, comprehensive personal protective equipment for all intubations, regular low fidelity simulation with 'sign-off' for all medical and nursing staff, senior clinician laryngoscopist and the introduction of pre-drawn medications. RESULTS: There were 783 patients, 136 in the COVID-19 era and 647 in the pre-COVID-19 comparator group. The rate of hypoxia was higher during the COVID-19 era compared to pre-COVID-19 (18.4% vs 9.6%, P < 0.005). This occurred despite the FAS rate remaining very high (95.6% vs 93.8%, P = 0.42) and intubation being undertaken by more senior laryngoscopists (consultant 55.9% during COVID-19 vs 22.6% pre-COVID-19, P < 0.001). Other adverse events were similar before and during COVID-19 (hypotension 12.5% vs 7.9%, P = 0.082; bradycardia 1.5% vs 0.5%, P = 0.21). Video laryngoscopy was more likely to be used during COVID-19 (95.6% vs 82.5%, P < 0.001) and induction of anaesthesia more often used ketamine (66.9% vs 42.3%, P < 0.001) and rocuronium (86.8% vs 52.1%, P < 0.001). CONCLUSIONS: This raft of modifications to ED intubation was associated with significant increase in hypoxia despite a very high FAS rate and more senior first laryngoscopist.

Preparation for airway management in Australia and New Zealand ICUs during the COVID -19 pandemic.

BACKGROUND: This paper aimed to describe the airway practices of intensive care units (ICUs) in Australia and New Zealand specific to patients presenting with COVID-19 and to inform whether consistent clinical practice was achieved. Specific clinical airway guidelines were endorsed in March 2020 by the Australian and New Zealand Intensive Care Society (ANZICS) and College of Intensive Care Medicine (CICM). METHODS AND FINDINGS: Prospective, structured questionnaire for all ICU directors in Australia and New Zealand was completed by 69 ICU directors after email invitation from ANZICS. The online questionnaire was accessible for three weeks during September 2020 and analysed by cloud-based software. Basic ICU demographics (private or public, metropolitan or rural) and location, purchasing, airway management practices, guideline uptake, checklist and cognitive aid use and staff training relevant to airway management during the COVID-19 pandemic were the main outcome measures. The 69 ICU directors reported significant simulation-based inter-professional airway training of staff (97%), and use of video laryngoscopy (94%), intubation checklists (94%), cognitive aids (83%) and PPE "spotters" (89%) during the airway management of patients with COVID-19. Tracheal intubation was almost always performed by a Specialist (97% of ICUs), who was more likely to be an intensivist than an anaesthetist (61% vs 36%). There was a more frequent adoption of specific airway guidelines for the management of COVID-19 patients in public ICUs (94% vs 71%) and reliance on specialist intensivists to perform intubations in private ICUs (92% vs 53%). CONCLUSION: There was a high uptake of a standardised approach to airway management in COVID-19 patients in ICUs in Australia and New Zealand, likely due to endorsement of national guidelines.