Tracheal Intubation in Patients with Coronavirus Disease 2019 (COVID-19): A Cross-Sectional Survey in China
The COVID-19 pandemic has caused significant loss of life globally, with tracheal intubation being a critical procedure in managing severe cases. Tracheal intubation is estimated to occur in 2.3% of hospitalized COVID-19 patients. As an aerosol-generating procedure, it poses a high risk of infection to healthcare workers. Balancing the need to avoid aerosol generation while ensuring adequate oxygenation during intubation presents unique challenges in COVID-19 patients compared to those with acute respiratory distress syndrome (ARDS). This study aimed to explore the differences in intubation practices between doctors who have performed tracheal intubation in COVID-19 patients and those who have not.
The study was supported by the Airway Management Group of the Chinese Society of Anesthesiology (CSA) and approved by the institutional review board of Beijing Hospital. Written informed consent was waived. Two versions of questionnaires were designed: Questionnaire A for doctors who had performed tracheal intubation in COVID-19 patients and Questionnaire B for those who had not. Both questionnaires collected information on personal details, hospital characteristics, and specific intubation practices, including airway assessment, preoxygenation, induction, and intubation methods. Questionnaire A also included the number of COVID-19 patients intubated by the respondent.
The questionnaires were distributed via the Wenjuanxing platform from March 18 to March 31, 2020. Responses were validated, and those from doctors who had not performed intubations or were from non-designated COVID-19 hospitals were excluded. A total of 3916 responses were received, with 153 valid responses for Questionnaire A and 3744 for Questionnaire B. These responses included 633 cases of intubation performed by 153 doctors.
The study revealed significant differences in intubation practices between the two groups. In the intubation group, 41 doctors performed tracheal intubation without an assistant, compared to 447 doctors in the non-intubation group who planned to do so. The modified Mallampati test, commonly used for airway assessment, was less frequently used by the intubation group (46% vs. 80%, P < 0.001). There were no significant differences in anti-fog measures and preoxygenation time between the groups. However, noninvasive mechanical ventilation (NIV) was more commonly used for preoxygenation by the intubation group (58% vs. 24%, P < 0.001).
In terms of induction, midazolam and etomidate were more frequently used by the non-intubation group (47% vs. 33%, P < 0.001 and 40% vs. 31%, P = 0.022, respectively). Rocuronium at doses over 0.9 mg/kg was preferred by the intubation group (42% vs. 25%, P < 0.001). Video laryngoscopes with disposable blades were similarly used by both groups, but fewer doctors in the intubation group confirmed endotracheal tube position by auscultation (9% vs. 22%, P < 0.001).
The study highlighted the importance of experienced assistants during tracheal intubation, as recommended by consensus guidelines. However, the shortage of doctors and personal protective equipment during the early stages of the pandemic may have influenced clinical practice. The avoidance of aerosol-generating procedures, such as the modified Mallampati test, was not universally understood, particularly by doctors in the non-intubation group. Preoxygenation for at least three minutes was recommended for COVID-19 patients, with NIV or high-flow nasal cannula (HFNC) often used before intubation.
Propofol, rocuronium, and sufentanil were the most commonly used anesthetics during induction. Propofol-induced hypotension was a concern, and midazolam and etomidate were recommended for hemodynamically unstable patients. Remifentanil or fentanyl was suggested to mitigate cardiovascular responses, while sufentanil was not recommended due to its long onset time. Rocuronium at 1.2 mg/kg was recommended by some guidelines, but ethnic differences may explain the lower doses used by Chinese doctors.
The study emphasized the need for skilled airway managers to perform tracheal intubation in COVID-19 patients. In China, anesthetists typically performed intubations in most hospitals. Differences in practices between anesthetists and other healthcare professionals, such as respiratory physicians, warrant further investigation.
In summary, modified rapid sequence induction and intubation using a video laryngoscope with disposable blades after preoxygenation were recommended for COVID-19 patients. Doctors without experience in tracheal intubation in COVID-19 patients lacked understanding of aerosol-generating procedures and the impact of protective gowns on intubation operations. Training programs should be implemented to prepare doctors for performing tracheal intubation under protective conditions and to minimize aerosol generation.
doi.org/10.1097/CM9.0000000000001635
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