COVID-19 and Risks Posed to Personnel During Endotracheal Intubation

Abstract

Health care personnel who care for critically ill patients with suspected or confirmed novel coronavirus disease 2019 (COVID-19) routinely participate in procedures, such as endotracheal intubation, that may create infectious aerosols. Among persons infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, approximately 8% will require endotracheal intubation and mechanical ventilation. 1 Aerosol-generating procedures have been described as "…procedures performed on patients [that] are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing." 2 Health Protection Scotland defines aerosol-generating procedures "as medical and patient care procedures that result in the production of airborne particles (aerosols) that create the potential for airborne transmission of infections that may otherwise only be transmissible by the droplet route." 3 Although there is no generally accepted and comprehensive list of aerosol-generating procedures performed during clinical care, examples include open suctioning of airways, sputum induction, manual ventilation, endotracheal intubation and extubation, noninvasive ventilation, bronchoscopy, and tracheotomy. 4 There is great interest in understanding the hazards posed by the range of potentially hazardous aerosol-generating procedures for the transmission of COVID-19 and other infectious diseases.Among the aerosol-generating procedures, performing endotracheal intubation is especially hazardous. The proceduralist performing endotracheal intubation is close to the patient's airway before, during, and after the procedure. The proceduralist is also likely to be present for the associated interventions that create respiratory aerosols, such as manual (bag) ventilation. A systematic literature review and meta-analysis that evaluated transmission of SARS coronavirus 1 (SARS-CoV-1) to health care personnel in association with exposure to aerosolgenerating procedures found a significantly increased odds ratio of 6.6. 5 This review also found an absolute risk increase of between 10% (cohort studies) and 15% (case-control studies) for transmission of SARS-CoV-1-associated infection to health care personnel performing intubation. 5 In addition, several other types of aerosol-generating procedures were also associated with increased risk for SARS-CoV-1, including tracheotomy, noninvasive ventilation, and manual ventilation prior to intubation. 5 However, tracheal intubation was the procedure most consistently associated with transmission across the studies reviewed. Given that high viral loads of SARS-CoV-2 are found in sputum and upper respiratory secretions of patients with COVID-19, endotracheal intubation should also be viewed as a highrisk procedure for exposure to and transmission of SARS-CoV-2. 6

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