key: cord-309324-vatugz84
authors: Sorbello, Massimiliano; El-Boghdadly, Kariem; Schumacher, Jan; Ahmad, Imran
title: Personal protective equipment, airway management and systematic reviews. Comment on Br J Anaesth 2020
date: 2020-06-30
journal: Br J Anaesth
DOI: 10.1016/j.bja.2020.06.038
sha: 
doc_id: 309324
cord_uid: vatugz84

nan

Editor -We read with interest the paper by Sanfilippo and colleagues 1 pandemic. Airway management with PPE carries significant challenges, including restricted movement, limited communication, impaired vision, loss of tactile sensitivity, and wearer discomfort. We thus agree with the need for a systematic review in this subject, however we wish to highlight some concerns regarding this study.

Firstly, the search reported by Sanfilippo and colleagues 1 appears to have missed some relevant and critically important studies. Although Sanfilippo and colleagues located only a single study examining anaesthetists as subjects, five other studies, all authored by and including anaesthetists, met inclusion criteria and would have been expected to be included in their analysis, three of which focused on the COVID-19 pandemic. These include two randomised crossover trials, 2-3 one crossover trial, 4 and two observational studies. [5] [6] A further study in a cardiac arrest setting might have been included also. 7 These omissions could reflect an incomplete search strategy, inadequate screening, or unclear inclusion criteria, and significantly undermine the validity and reliability of the results and interpretation.

Secondly, for the outcome metrics sought, success rate and time to successful tracheal intubation, critical operator chracteristics were not considered. In particular, the background and experience of airway operators must be factored in as different levels of experience can cause poor performance 8 rather than the PPE itself. The authors did not examine or report this key element of the included studies.

Thirdly, the authors compared a highly variable and diverse PPE baseline (in diverse population studies). For example, one study compared outcomes after tracheal intubation of a manikin with either a Glidescope or a Macintosh laryngoscope with participants wearing Hazmat PPE, 9 and another examined the AirwayScope with participants wearing "chemical, biological, radiation and nuclear PPE". 10 In the first study a complete hazmat suit with PAPR was used by 1 st -3 rd year emergency medicine residents, whereas in the second a group of 19 volunteers with "some prior experience of tracheal intubations on human patients using a Macintosh laryngoscope (mean number of intubations, 1.13+/-1.31)" was using "nylon shirt and pants, antigas mask, gloves and rubber boots", which are intuitively less cumbersome compared with a full hazmat suit. This variation is emphasised in the legend of Table 1 in Sanfilippo and colleagues' paper, 1 which reveals the diversity of the included PPE, ranging from respirator masks to powered air-purifying respirators (PAPRs), which would have significant differences in their influence on technical performance.

The importance of simulation and training in airway management, particularly in combination with the physical and cognitive challenges imposed by PPE has been reported elsewhere. [11] [12] [13] [14] We agree with the authors that training is of utmost importance; on the other hand, we want to emphasize other priority factors such as the need to identify dedicated airway teams and intubation spots, 15 and the need for team preparedness and pre-procedural planning (including cognitive aids and airway management and PPE donning/doffing checklists), [12] [13] [14] and the need for clear indications for correct PPE and operative instructions to improve user compliance and acceptance. 16 We cannot underestimate the additional mental workload imposed by the clinical scenario and by the fear of self-infection which could never be reproduced even in the highest fidelity simulation.

It is encouraging that Sanfilippo and colleagues have attempted to synthesise data on this practice. However significant limitations in their data hamper our ability to interpret the evidence base, but their data do highlight that the real concern is not measuring how limited airway management is by PPE, but rather the need for better understanding of PPE diversity, correct use of PPE and development and training in new techniques, protocols and devices to overcome such difficulties. Otherwise, as with the Chinese proverb, when the wise points the moon, the fool looks at the finger. 

Systematic review of simulated airway management whilst wearing personal protective equipment

A randomised crossover simulation study comparing the impact of chemical, biological, radiological or nuclear substance personal protection equipment on the performance of advanced life support interventions

The impact of respiratory protective equipment on difficult airway management: a randomised, crossover, simulation study

The aerosol box for intubation in coronavirus disease 2019 patients: an in-situ simulation crossover study

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Comparison of three tracheal intubation methods for reducing droplet spread for use in COVID-19 patients

Comparison of powered and conventional air-purifying respirators during simulated resuscitation of casualties contaminated with hazardous substances

Device or target? A paradigm shift in airway management: implications for guidelines, clinical practice and teaching

Intubation Efficiency and Perceived Ease of Use of Video Laryngoscopy vs Direct Laryngoscopy While Wearing HazMat PPE: A Preliminary High-fidelity Mannequin Study

Utility of the Pentax-AWS in performing tracheal intubation while wearing chemical, biological, radiation and nuclear personal protective equipment: a randomised crossover trial using a manikin

The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists

Outbreak of a new coronavirus: what anaesthetists should know

Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group

COVID-19: Intubation kit, intubation team or intubation spots?

Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis