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Airway management for pandemic: a move towards universal video laryngoscope?

Time : 2020-09-25 Hits : 71

Airway  management  for pandemic: a move  towards universal video laryngoscope?During the current outbreak of pandemic, frontline health-care workers are at high risk of contamination and spreading the infection. Hospital-related infections have been widely reported, with health-care professionals being dis- proportionately affected. Health-care  workers  who are involved in airway management of severely ill patients with pandemic are particularly at risk due to the use of intubators; for example, a proportion of anaesthesiologists working in Wuhan, China, became infected after performing endotracheal intubation on patients with confirmed pandemic. Intubation can trigger aerosolisation of small particles containing the virus, and these particles can travel further distances when suspended in the air than when not aerosolised and be inhaled, increasing the risk of transmission. Therefore, anaesthesiologists, intensivists, and others  members of the airway management team, should be careful when performing tracheal intubation for patients with pandemic.

Considering that any patient who is admitted to

the intensive care unit (ICU) might be infected with severe acute respiratory syndrome pandemic 2 (SARS-CoV-2), we present a video of tracheal intubation performed in an operating room, using two different devices for laryngoscopy (video). As recommended by airway management societies worldwide, we used a rapid sequence induction, and face mask ventilation was avoided. In part 1 of the video, the use of standard Macintosh laryngoscope for tracheal intubation places the face of the intubator very close to the patient, which puts the intubator at high risk of contamination from airway secretions. In part 2 of the video, the use of a video laryngoscope allows the intubator to be further away from the patient and is therefore at reduced risk of exposure to airway secretions and contamination. The use of a single-use blade might also reduce the risk of patient-to-provider transmission compared with use of a reusable blade.

video laryngoscopy is an important tool in anticipated

and unanticipated difficult intubation. Videolaryngoscopes are designed to improve visualisation of the glottis, aiming to decrease the time to successful intubation, increase first attempt intubation success rate, increase overall intubation success rate, reduce applied force, and reduce intubation-related complications.

After wide implementation of video laryngoscopy in operating rooms, the rate of difficult and failed intubations by skilled providers have declined significantly. For critically ill patients, the use of videolaryngoscopes is more recent

than in operating rooms; however, their effectiveness in increasing first attempt success and reducing difficult intubation or complications related to intubation remains controversial. However, after appropriate training and education, videolaryngoscopes can also be of great help for an experienced operator in both non-difficult and difficult intubation procedures in the ICU setting. This reduction of difficult intubation could thereby reduce patient-to-provider transmission of infectious disease and SARS-CoV-2 infection.

New respiratory viruses are emerging each year; to

minimise the spread of disease, preventive measures should be taken for each tracheal intubation performed, such as the use of videolaryngoscopes, which allow indirect visualisation of the glottis. In the UK, guidance from the Royal College of Anaesthetists and the Intensive Care Society advises the use of  videolaryngoscopes for intubation of patients with pandemic. Worldwide, data suggest that 80% of intubations of these patients have been performed with videolaryngoscopes. It is worth noting that proficiency with videolaryngoscope is unlikely to be achieved if their use remains limited to predicted or unpredicted difficult intubation. Developing expertise in video laryngoscopy will require frequent rather than occasional use, both in operating rooms and in ICUs.

Videolaryngoscopes do come in several varieties,

and anaesthetists have to be familiar with the  particular videolaryngoscope they are using. The UK national guidelines do also advocate that the most senior anaesthetist intubates patients, rather than junior anaesthetists or for those not familiar with the videolaryngoscope available, to avoid prolonging of the intubation attempt. The transition to video laryngoscopy as a routine firstline option throughout anaesthetic and ICU practice has been reported and is currently performed in the Montpellier University hospital and other hospitals across France. We believe that all patients with pandemic, and ideally every patient during the pandemic, should be intubated using video laryngoscopy.

Lancet Respir Med 2020

Published Online

May 5, 2020

https://doi.org/10.1016/ S2213-2600(20)30221-6

For more on infection in health- care professionals see Correspondence

Lancet Respir Med 2020; 8: e13

For more on airway management for pandemic see Correspondence

Lancet Respir Med 2020; 8: e19

For more on support for medical professionals see Correspondence Lancet 2020;

395: e42–43

See Online for video

For more on video laryngoscopy

see Crit Care 2019; 23: 221 and

Br J Anaesth 2015; 115: 827–48

For more on declining failed and difficult intubation rates see Br J Anaesth 2019;

122: 245–54

For more on video laryngoscopy in anaesthetic and intensive care departments see