A prospective, observational, cohort study of airway management of patients with COVID-19 by specialist tracheal intubation teams

Abstract

Purpose Because of the anticipated surge in cases requiring intensive care unit admission, the high aerosolgenerating risk of tracheal intubation, and the specific requirements in coronavirus disease (COVID-19) patients, a dedicated Mobile Endotracheal Rapid Intubation Team (MERIT) was formed to ensure that a highly skilled team would be deployed to manage the airways of this cohort of patients. Here, we report our intubation team experience and activity as well as patient outcomes during the COVID-19 pandemic. Methods The MERIT members followed a protocolized early tracheal intubation model. Over a seven-week period during the peak of the pandemic, prospective data were collected on MERIT activity, COVID-19 symptoms or diagnosis in the team members, and demographic, procedural, and clinical outcomes of patients. Results We analyzed data from 150 primary tracheal intubation episodes, with 101 (67.3%) of those occurring in men, and with a mean (standard deviation) age of 55.7 (13.8) yr. Black, Asian, and minority ethnic groups accounted for 55.7% of patients. 91.3% of tracheal intubations were performed with videolaryngoscopy, and the first pass success rate was 88.0%. The 30-day survival was 69.2%, and the median [interquartile range] length of critical care stay was 11 [6-20] days and of hospital stay was 12 [7-22] days. Seven (11.1%) MERIT healthcare professionals self-isolated because of COVID-19 symptoms, with a total 41 days of clinical work lost. There was one reported incident of a breach of personal protective equipment and multiple anecdotal reports of doffing breaches. Conclusion We have shown that a highly skilled designated intubation team, following a protocolized, early tracheal intubation model may be beneficial in improving patient and staff safety, and could be considered by other institutions in future pandemic surges.

Endotracheal Intubation in Patients With COVID-19 By Emergency Physicians in The Tokyo Metropolitan Area

“…The success rate for the rst attempt at intubation was quite high at 85%, but this was relatively lower than that reported in three earlier studies on this topic [8][9][10]. Hypotension and hypoxia each occurred in approximately 27% of cases, which was clinically relevant.…”

“…Given the risks of infection transmission, several protocols and safety devices are recommended for use in this context [4][5][6][7]. To date, there have only been two observational studies regarding emergency tracheal intubation by anesthesiologists in China [8,9], one prospective study from the UK [10], and one international cohort study among emergency physicians [11], though only 1.6% of patients with COVID-19 underwent tracheal intubation in the latter study. However, the success rate, complications, barrier enclosure use, type of personal protective equipment (PPE), and operator safety are unknown when emergency tracheal intubation is performed by emergency physicians for patients with COVID-19.…”

In reply: The criteria used to justify endotracheal intubation of patients with COVID-19 are worrisome

“…We thank Dr. Tobin for his interest 1 in our paper 2 and acknowledge his many years of clinical experience. The pandemic has certainly introduced many unknowns into clinical practice and the decision to implement a protocolized approach to the management of coronavirus disease (COVID-19) patients in our institution was not taken lightly.…”

Indications for Tracheal Intubation in Patients With Coronavirus Disease 2019 (COVID-19)

“…Moreover, despite a long-standing debate (since the pandemic started) between supporters of “early” vs. “late” tracheal intubation, there is no clear evidence of the superiority of one strategy over the other in terms of outcome. [12] For example, some authors recently claimed about improved results with an “early intubation” protocolized approach in COVID-19 patients [13] , while others raised concerns about a possible patient self-inflicted lung injury (P-SILI) in patients with severe respiratory failure left in spontaneous breath. [14] However, the criteria used for tracheal intubation in this “early intubation protocol” have been heavily criticized 15 , and the observational design of the study does not allow to prove that those patients would have had a worse outcome with a different treatment.…”