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Maintaining Prehospital Intubation Success with COVID-19 Personal Protective Precautions

Published online by Cambridge University Press:  12 September 2022

Pascale Avery Open the ORCID record for Pascale Avery [Opens in a new window] ,
Sam McAleer ,
David Rawlinson ,
Stuart Gill  and
David Lockey
Pascale Avery*
Affiliation:
Emergency Retrieval and Transfer Service (EMRTS) Wales Air Ambulance, Llanelli Gate, Dafen, Wales, United Kingdom
Sam McAleer
Affiliation:
Emergency Retrieval and Transfer Service (EMRTS) Wales Air Ambulance, Llanelli Gate, Dafen, Wales, United Kingdom
David Rawlinson
Affiliation:
Emergency Retrieval and Transfer Service (EMRTS) Wales Air Ambulance, Llanelli Gate, Dafen, Wales, United Kingdom
Stuart Gill
Affiliation:
Emergency Retrieval and Transfer Service (EMRTS) Wales Air Ambulance, Llanelli Gate, Dafen, Wales, United Kingdom
David Lockey
Affiliation:
Emergency Retrieval and Transfer Service (EMRTS) Wales Air Ambulance, Llanelli Gate, Dafen, Wales, United Kingdom
*
Correspondence: Pascale Avery, BMBS, MSc, FHEA, MRCEM Emergency Medical Retrieval and Transfer Service (EMRTS Cymru) - EMRTS Llanelli Gate, Wales Air Ambulance Charity, Ffordd Angel Dafen, Llanelli SA14 8LQ, United Kingdom E-mail: pascale.avery@nhs.net
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Abstract

Background:

Tracheal intubation is a high-risk intervention for exposure to airborne infective pathogens, including the novel coronavirus disease 2019 (COVID-19). During the recent pandemic, personal protective equipment (PPE) was essential to protect staff during intubation but is recognized to make the practical conduct of anesthesia and intubation more difficult. In the early phase of the coronavirus pandemic, some simple alterations were made to the emergency anesthesia standard operating procedure (SOP) of a prehospital critical care service to attempt to maintain high intubation success rates despite the challenges posed by wearing PPE. This retrospective observational cohort study aims to compare first-pass intubation success rates before and after the introduction of PPE and an altered SOP.

Methodology:

A retrospective observational cohort study was conducted from January 1, 2019 through August 30, 2021. The retrospective analysis used prospectively collected data using prehospital electronic patient records. Anonymized data were held in Excel (v16.54) and analyzed using IBM SPSS Statistics (v28). Patient inclusion criteria were those of all ages who received a primary tracheal intubation attempt outside the hospital by critical care teams. March 27, 2020 was the date from which the SOP changed to mandatory COVID-19 SOP including Level 3 PPE – this date is used to separate the cohort groups.

Results:

Data were analyzed from 1,266 patients who received primary intubations by the service. The overall first-pass intubation success rate was 89.7% and the overall intubation success rate was 99.9%. There was no statistically significant difference in first-pass success rate between the two groups: 90.3% in the pre-COVID-19 group (n = 546) and 89.3% in the COVID-19 group (n = 720); Pearson chi-square 0.329; P = .566. In addition, there was no statistical difference in overall intubation success rate between groups: 99.8% in the pre-COVID-19 group and 100.0% in the COVID-19 group; Pearson chi-square 1.32; P = .251.

Non-drug-assisted intubations were more than twice as likely to require multiple attempts in both the pre-COVID-19 group (n = 546; OR = 2.15; 95% CI, 1.19-3.90; P = .01) and in the COVID-19 group (n = 720; OR = 2.5; 95% CI, 1.5-4.1; P = <.001).

Conclusion:

This study presents simple changes to a prehospital intubation SOP in response to COVID-19 which included mandatory use of PPE, the first intubator always being the most experienced clinician, and routine first use of video laryngoscopy (VL). These changes allowed protection of the clinical team while successfully maintaining the first-pass and overall success rates for prehospital tracheal intubation.

Keywords

apneic oxygenationCOVID-19emergency anesthesiarapid sequence inductionstandard operating proceduresvideo laryngoscopy
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 37 , Issue 6 , December 2022 , pp. 783 - 787
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Copyright
© The Author(s), 2022. Published by Cambridge University Press on behalf of the World Association for Disaster and Emergency Medicine

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References

Fowler, RA, Guest, CB, Lapinsky, SE, et al. Transmission of severe acute respiratory syndrome during intubation and mechanical ventilation. Am J Respir Crit Care Med. 2004;169(11):1198–1202.CrossRefGoogle ScholarPubMed
Tran, K, Cimon, K, Severn, M, Pessoa-Silva, CL, Conly, J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797.CrossRefGoogle ScholarPubMed
Public Health England. COVID-19: infection prevention and control guidance 2020. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/wuhan-novel-coronavirus-wn-cov-infection-prevention-and-control-guidance#mobile-healthcare-equipment. Accessed May 2022.Google Scholar
Centre for Disease Control and Prevention. Interim US Guidance for risk assessment and work restrictions for healthcare personnel with potential exposure to COVID-19. Updated September 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html. Accessed May 2022.Google Scholar
El-Boghdadly, K, Wong, DJN, Owen, R, et al. Risks to healthcare workers following tracheal intubation of patients with COVID-19: a prospective international multicenter cohort study. Anesthesia. 2020;75(11):1437–1447.CrossRefGoogle Scholar
Chan-Yeung, M. Severe acute respiratory syndrome (SARS) and healthcare workers. Int J Occup Environ Health. 2004;10(4):421–427.CrossRefGoogle ScholarPubMed
O’Meara, M GM, Phipps, T. Clinical Standard Operating Procedure (CSOP 4b): Emergency Anesthesia. Wales, UK: Emergency Medical Retrieval and Transfer Service (EMRTS). EMRTS internal documents.Google Scholar
Lockey, DJ, Crewdson, K, Davies, G, et al. AAGBI: safer pre-hospital anesthesia 2017: Association of Anesthetists of Great Britain and Ireland. Anesthesia. 2017;72(3):379–390.Google ScholarPubMed
Frerk, C, Mitchell, VS, McNarry, AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–848.CrossRefGoogle Scholar
UK Health Security Agency. Guidance: COVID-19: personal protective equipment use for aerosol generating procedures. GOV.UK2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1020015/20200821_COVID-19_Airborne_precautions_Putting_on_PPE_gown_version.pdf. Accessed May 2022.Google Scholar
Cook, TM. Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic - a narrative review. Anesthesia. 2020;75(7):920–927.Google ScholarPubMed
Nicolle, L. SARS safety and science. Can J Anaesth. 2003;50(10):983–985.CrossRefGoogle ScholarPubMed
Hughes J COB. Operational Standard Operating Procedure (OSOP): COVID-19. Wales, UK: Emergency Medical Retrieval and Transfer Service (EMRTS).Google Scholar
Brown, J, Gregson, FKA, Shrimpton, A, et al. A quantitative evaluation of aerosol generation during tracheal intubation and extubation. Anesthesia. 2021;76(2):174–181.CrossRefGoogle ScholarPubMed
Gill, S. Clinical Standard Operating Procedure (CSOP 4c): Governance Arrangements for Intubations by CCPs during PHEA. Wales, UK: Emergency Medical Retrieval and Transfer Service (EMRTS).Google Scholar
Lewis, SR, Butler, AR, Parker, J, Cook, TM, Smith, AF. Video laryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Cochrane Database Syst Rev. 2016;11:CD011136.Google ScholarPubMed
Arulkumaran, N, Lowe, J, Ions, R, Mendoza, M, Bennett, V, Dunser, MW. Video laryngoscopy versus direct laryngoscopy for emergency orotracheal intubation outside the operating room: a systematic review and meta-analysis. Br J Anaesth. 2018;120(4):712–724.CrossRefGoogle ScholarPubMed
Meng, L, Qiu, H, Wan, L, et al. Intubation and ventilation amid the COVID-19 outbreak: Wuhan’s experience. Anesthesiology. 2020;132(6):1317–1332.CrossRefGoogle ScholarPubMed
Miller, L, Lukovic, E, Wagener, G. Guiding airway management and personal protective equipment for COVID-19 intubation teams. Br J Anaesth. 2020;125(3):e288–e290.CrossRefGoogle ScholarPubMed
Nabecker, S, Greif, R, Kotarlic, M, Kleine-Brueggeney, M, Riggenbach, C, Theiler, L. Outdoor performance of different video laryngoscopes on a glacier: a manikin study. Emergencias. 2016;28(4):216–222.Google Scholar
Pieters, BM, van Zundert, AA. Video laryngoscopes differ substantially in illumination of the oral cavity: a manikin study. Indian J Anaesth. 2016;60(5):325–329.CrossRefGoogle Scholar
Trimmel, H, Kreutziger, J, Fitzka, R, et al. Use of the GlideScope Ranger video laryngoscope for emergency intubation in the prehospital setting: a randomized control trial. Crit Care Med. 2016;44(7):e470–476.Google ScholarPubMed
Sakles, JC, Corn, GJ, Hollinger, P, Arcaris, B, Patanwala, AE, Mosier, JM. The impact of a soiled airway on intubation success in the emergency department when using the GlideScope or the direct laryngoscope. Acad Emerg Med. 2017;24(5):628–636.CrossRefGoogle ScholarPubMed
Koo, A, Walsh, R, Knutson, T, et al. Comparison of intubation using personal protective equipment and standard uniform in simulated cadaveric models. Mil Med. 2018;183(suppl_1):216–218.CrossRefGoogle ScholarPubMed
Garner, A, Laurence, H, Lee, A. Practicality of performing medical procedures in chemical protective ensembles. Emerg Med Australas. 2004;16(2):108–113.Google ScholarPubMed
Scott Taylor, R, Pitzer, M, Goldman, G, Czysz, A, Simunich, T, Ashurst, J. Comparison of intubation devices in Level C personal protective equipment: a cadaveric study. Am J Emerg Med. 2018;36(6):922–925.Google Scholar
Caglar, A, Kacer, I, Hacimustafaoglu, M, Ozturk, B, Ozturk, S. Impact of personal protective equipment on prehospital endotracheal intubation performance in simulated manikin. Australas Emerg Care. 2021;24(3):235–239.Google ScholarPubMed
Sanfilippo, F, Tigano, S, Palumbo, GJ, Astuto, M, Murabito, P. Systematic review of simulated airway management whilst wearing personal protective equipment. Br J Anaesth. 2020;125(3):e301–e305.CrossRefGoogle ScholarPubMed
von Elm, E, Altman, DG, Egger, M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–1457.Google ScholarPubMed
Sunde, GA, Heltne, JK, Lockey, D, et al. Airway management by physician-staffed Helicopter Emergency Medical Services - a prospective, multicenter, observational study of 2,327 patients. Scand J Trauma Resusc Emerg Med. 2015;23:57.CrossRefGoogle ScholarPubMed
Gellerfors, M, Fevang, E, Backman, A, et al. Pre-hospital advanced airway management by anesthetist and nurse anesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations. Br J Anaesth. 2018;120(5):1103–1109.CrossRefGoogle ScholarPubMed
Lockey, DJ, Crewdson, K. Pre-hospital anesthesia: no longer the ‘poor relative’ of high quality in-hospital emergency airway management. Br J Anaesth. 2018;120(5):898–901.Google ScholarPubMed
Wong, DJN, El-Boghdadly, K, Owen, R, et al. Emergency airway management in patients with COVID-19: a prospective international multicenter cohort study. Anesthesiology. 2021;135(2):292–303.Google ScholarPubMed
Trembley, LL, Tobias, AZ, Schillo, G, et al. A multidisciplinary intubation algorithm for suspected COVID-19 patients in the emergency department. West J Emerg Med. 2020;21(4):764–770.CrossRefGoogle ScholarPubMed
De Jong, A, Pardo, E, Rolle, A, Bodin-Lario, S, Pouzeratte, Y, Jaber, S. Airway management for COVID-19: a move towards universal video laryngoscope? Lancet Respir Med. 2020;8(6):555.CrossRefGoogle Scholar
Lockhart, SL, Duggan, LV, Wax, RS, Saad, S, Grocott, HP. Personal protective equipment (PPE) for both anesthesiologists and other airway managers: principles and practice during the COVID-19 pandemic. Can J Anaesth. 2020;67(8):1005–1015.Google ScholarPubMed
Foley, LJ, Urdaneta, F, Berkow, L, et al. Difficult airway management in adult coronavirus disease 2019 patients: statement by the Society of Airway Management. Anesth Analg. 2021;133(4):876–890.CrossRefGoogle Scholar
Hart, J, Tracy, R, Johnston, M, et al. Recommendations for prehospital airway management in patients with suspected COVID-19 infection. West J Emerg Med. 2020;21(4):809–812.CrossRefGoogle ScholarPubMed
Hawkins, A, Stapleton, S, Rodriguez, G, Gonzalez, RM, Baker, WE. Emergency tracheal intubation in patients with COVID-19: a single-center, retrospective cohort study. West J Emerg Med. 2021;22(3):678–686.CrossRefGoogle ScholarPubMed