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

Wenlong Yao, Tingting Wang, Bailin Jiang, Feng Gao, Li Wang, Hongbo Zheng, Weimin Xiao, Shanglong Yao, Wei Mei, Xiangdong Chen, Ailin Luo, Liang Sun, Tim Cook, Elizabeth Behringer, Johannes M Huitink, David T Wong, Meghan Lane-Fall, Alistair F McNarry, Barry McGuire, Andrew Higgs, Amit Shah, Anil Patel, Mingzhang Zuo, Wuhua Ma, Zhanggang Xue, Li-Ming Zhang, Wenxian Li, Yong Wang, Carin Hagberg, Ellen P O'Sullivan, Lee A Fleisher, Huafeng Wei, collaborators, Zhiyong Peng, Hansheng Liang, Koji Nishikawa, Wenlong Yao, Tingting Wang, Bailin Jiang, Feng Gao, Li Wang, Hongbo Zheng, Weimin Xiao, Shanglong Yao, Wei Mei, Xiangdong Chen, Ailin Luo, Liang Sun, Tim Cook, Elizabeth Behringer, Johannes M Huitink, David T Wong, Meghan Lane-Fall, Alistair F McNarry, Barry McGuire, Andrew Higgs, Amit Shah, Anil Patel, Mingzhang Zuo, Wuhua Ma, Zhanggang Xue, Li-Ming Zhang, Wenxian Li, Yong Wang, Carin Hagberg, Ellen P O'Sullivan, Lee A Fleisher, Huafeng Wei, collaborators, Zhiyong Peng, Hansheng Liang, Koji Nishikawa

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.

Keywords: ARDS; COVID-19; airway management; consensus recommendations; critical care; infection prevention and control; pneumonia; respiratory failure; tracheal intubation.

Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Figures

Fig 1
Fig 1
Two layers of personal protective equipment. (a) Inner layer. (b) Outer layer with a face field. (c) Outer layer with a hood without a powered air-purifying respirator (PAPR). (d) Outer layer with a hood PAPR.
Fig 2
Fig 2
Flow chart of recommended tracheal intubation procedure in patients with coronavirus disease 2019 (COVID-19). A suggested strategy based on clinical data for tracheal intubation in 202 patients with COVID-19 from Wuhan, China, and on recommendations from a group of international experts in airway management. Etco2, end-tidal carbon dioxide; Fio2, fraction of inspired oxygen; HEPA, high-efficiency particulate air; HFNO, high-flow nasal oxygen; PPE, personal protective equipment.

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