Staff safety during emergency airway management for COVID-19 in Hong Kong
Authors: Jonathan Chun-Hei Cheung, Lap Tin Ho, Justin Vincent Cheng, Esther Yin Kwan Cham, Koon Ngai Lam
Journal: The Lancet Respiratory Medicine (2020)

Medical professionals caring for patients with coronavirus disease 2019 (COVID-19) are at high risk of contracting the infection.1Chang D Xu H Rebaza A Sharma L Cruz CSD Protecting health-care workers from subclinical coronavirus infection.Lancet Respir Med. 2020; (published online Feb 13.)https://doi.org/10.1016/S2213-2600(20)30066-7Summary Full Text Full Text PDF PubMed Scopus (457) Google Scholar Aerosol-generating procedures, such as non-invasive ventilation (NIV), high-flow nasal cannula (HFNC), bag-mask ventilation, and intubation are of particularly high risk.2Tran 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; 7e35797Crossref PubMed Scopus (1322) Google Scholar We hereby describe the approach of our local intensive care unit (North District Hospital, Sheung Shui, Hong Kong) to managing the risks to health-care staff, while maintaining optimal and high-quality care. All medical personnel involved in the management of patients with suspected COVID-19 must adhere to airborne precautions, hand hygiene, and donning of personal protective equipment. All aerosol-generating procedures should be done in an airborne infection isolation room. Double-gloving, as a standard practice at our unit, might provide extra protection and minimise spreading via fomite contamination to the surrounding equipment after intubation.3Casanova LM Rutala WA Weber DJ Sobsey MD Effect of single- versus double-gloving on virus transfer to health care workers' skin and clothing during removal of personal protective equipment.Am J Infect Control. 2012; 40: 369-374Summary Full Text Full Text PDF PubMed Scopus (78) Google Scholar An experiment with a mannikin showed that NIV or HFNC, when well applied with an optimal fit, only lead to minimal dispersion of exhaled air.4Hui DS Chow BK Lo T et al.Exhaled air dispersion during high flow nasal cannula therapy versus CPAP via different masks.Eur Respir J. 2019; 531802339Crossref PubMed Scopus (252) Google Scholar However, the specific NIV and HFNC models and modes tested in the study are not universally used across all hospitals. Therefore, to avoid confusion and potential harm, we do not recommend using NIV or HFNC until the patient is cleared of COVID-19. Airway devices providing 6 L/min or more of oxygen are considered high-flow5Yu IT Xie ZH Tsoi KK et al.Why did outbreaks of severe acute respiratory syndrome occur in some hospital wards but not in others?.Clin Infect Dis. 2007; 44: 1017-1025Crossref PubMed Scopus (148) Google Scholar and we discourage their use if an airborne infection isolation room is unavailable. We recommend that endotracheal intubation is done by an expert specialised in the procedure, and early intubation should be considered in a patient with deteriorating respiratory condition. For all cases, backup airway plans should be ready. We recommend avoiding bag mask ventilation for as long as possible; and optimising preoxygenation with non-aerosol-generating means. Methods include the bed-up-head-elevated position, airway manoeuvres, use of a positive end expiratory pressure valve, and airway adjuncts. If manual bagging is required, we suggest gentle ventilation via a supraglottic device instead of bag mask ventilation. Although no robust evidence is available to show that the use of supraglottic devices are less aerosol-generating than BMV, the devices are easy to insert and can achieve sufficient seal pressure. They also help to spare manpower and thus reduce staff exposure. Furthermore, many newer generation supraglottic devices provide a conduit for unassisted intubation. To monitor the pattern of ventilation, a continuous waveform capnography monitoring device should be used; an advantage of this being that a correct waveform accurately reflects correct endotracheal tube placement. Furthermore, physiologically, it might give clues on the adequacy of the seal when using supraglottic devices. Rapid sequence induction is the technique of choice for emergency intubation. Some operators prefer rocuronium over suxamethonium for its longer half-life, which effectively prevents coughing or vomiting that might occur when the shorter acting muscle relaxant subsides after an unsuccessful first attempt. When rocuronium is used, a full 1·2 mg/kg intravenous dose should be administered to achieve a similar onset time to suxamethonium. Once an endotracheal tube is inserted, its cuff should be inflated immediately to avoid leakage. The endotracheal tube should be connected to the ventilator via a filter and a waveform capnography monitoring device, with ventilation only started after pilot balloon inflation is confirmed. The capnography monitoring device waveform can subsequently confirm the correct positioning of the endotracheal tube. Only then should the physician exclude bronchial intubation by five-point auscultation. We declare no competing interests. Protecting health-care workers from subclinical coronavirus infectionHealth-care workers face an elevated risk of exposure to infectious diseases, including the novel coronavirus (COVID-19) in China. It is imperative to ensure the safety of health-care workers not only to safeguard continuous patient care but also to ensure they do not transmit the virus. COVID-19 can spread via cough or respiratory droplets, contact with bodily fluids, or from contaminated surfaces.1 According to recent guidelines from the China National Health Commission, pneumonia caused by COVID-19 was included as a Group B infectious disease, which is in the same category as other infectious viruses such as severe acute respiratory syndrome (SARS) and highly pathogenic avian influenza (HPAI). Full-Text PDF Respiratory support for patients with COVID-19 infectionAs of Feb 27, 2020, coronavirus disease 2019 (COVID-19) has affected 47 countries and territories around the world.1 Xiaobo Yang and colleagues2 described 52 of 710 patients with confirmed COVID-19 admitted to an intensive care unit (ICU) in Wuhan, China. 29 (56%) of 52 patients were given non-invasive ventilation at ICU admission, of whom 22 (76%) required further orotracheal intubation and invasive mechanical ventilation. The ICU mortality rate among those who required non-invasive ventilation was 23 (79%) of 29 and among those who required invasive mechanical ventilation was 19 (86%) of 22. Full-Text PDF COVID-19 outbreak: less stethoscope, more ultrasoundIn their Correspondence in The Lancet Respiratory Medicine, Jonathan Cheung and colleagues stressed the need to ensure staff safety in the airway management of patients with 2019 novel coronavirus disease (COVID-19).1 This safety should be guaranteed from the patient's first assessment. In fact, maintaining the safety of the doctor, who meets many people during his daily activity, avoids the spread of the disease to other patients and the possible creation of new epidemic outbreaks. However, patients with fever and respiratory symptoms do still need to be seen. Full-Text PDF