Introduction This statement was planned on 11 March 2020 to provide clinical guidance and aid staff preparation for the coronavirus disease 2019 (COVID‐19) pandemic in Australia and New Zealand. It has been widely endorsed by relevant specialty colleges and societies. Main recommendations Generic guidelines exist for the intubation of different patient groups, as do resources to facilitate airway rescue and transition to the “can't intubate, can't oxygenate” scenario. They should be followed where they do not contradict our specific recommendations for the COVID‐19 patient group. Consideration should be given to using a checklist that has been specifically modified for the COVID‐19 patient group. Early intubation should be considered to prevent the additional risk to staff of emergency intubation and to avoid prolonged use of high flow nasal oxygen or non‐invasive ventilation. Significant institutional preparation is required to optimise staff and patient safety in preparing for the airway management of the COVID‐19 patient group. The principles for airway management should be the same for all patients with COVID‐19 (asymptomatic, mild or critically unwell). Safe, simple, familiar, reliable and robust practices should be adopted for all episodes of airway management for patients with COVID‐19. Changes in management as a result of this statement Airway clinicians in Australia and New Zealand should now already be involved in regular intensive training for the airway management of the COVID‐19 patient group. This training should focus on the principles of early intervention, meticulous planning, vigilant infection control, efficient processes, clear communication and standardised practice.
The coronavirus disease 2019 pandemic has led to the manufacturing of novel devices to protect clinicians from the risk of transmission, including the aerosol box for use during tracheal intubation. We evaluated the impact of two aerosol boxes (an early-generation box and a latest-generation box) on intubations in patients with severe coronavirus disease 2019 with an in-situ simulation crossover study. The simulated process complied with the Safe Airway Society coronavirus disease 2019 airway management guidelines. The primary outcome was intubation time; secondary outcomes included first-pass success and breaches to personal protective equipment. All intubations were performed by specialist (consultant) anaesthetists and video recorded. Twelve anaesthetists performed 36 intubations. Intubation time with no aerosol box was significantly shorter than with the early-generation box (median (IQR [range]) 42.9 (32.9-46.9 [30.9-57.6])s vs. 82.1 (45.1-98.3 [30.8-180.0])s p = 0.002) and the latest-generation box (52.4 (43.1-70.3 [35.7-169.2])s, p = 0.008). No intubations without a box took more than 1 min, whereas 14 (58%) intubations with a box took over 1 min and 4 (17%) took over 2 min (including one failure). Without an aerosol box, all anaesthetists obtained first-pass success. With the early-generation and latest-generation boxes, 9 (75%) and 10 (83%) participants obtained first-pass success, respectively.
Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events.OBJECTIVE To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients. DESIGN, SETTING, AND PARTICIPANTSThe International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents. EXPOSURES Tracheal intubation.MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality. RESULTSOf 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%. CONCLUSIONS AND RELEVANCEIn this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events-in particular cardiovascular instability-were observed frequently.
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