key: cord-0797328-mtutcvaf authors: de Alencar, Julio Cesar Garcia; Marques, Bruno; Marchini, Julio Flavio Meirelles; Marino, Lucas Oliveira; Ribeiro, Sabrina Correa da Costa; Bueno, Cauê Gasparotto; da Cunha, Victor Paro; Lazar Neto, Felippe; Valente, Fernando Salvetti; Rahhal, Hassan; Pereira, Juliana Batista Rodrigues; Padrão, Eduardo Messias Hirano; Wanderley, Annelise Passos Bispos; Costa, Millena Gomes Pinheiro; Brandão Neto, Rodrigo Antonio; Souza, Heraldo Possolo title: First‐attempt intubation success and complications in patients with COVID‐19 undergoing emergency intubation date: 2020-08-12 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12219 sha: eb446611f8c2a3c382a56d4ed65fc07238abeed4 doc_id: 797328 cord_uid: mtutcvaf OBJECTIVES: To evaluate the first‐attempt success rates and complications of endotracheal intubation of coronavirus disease 2019 (COVID‐19) patients by emergency physicians. METHODS: This prospective observational study was conducted from March 24, 2020 through May 28, 2020 at the emergency department (ED) of an urban, academic trauma center. We enrolled patients consecutively admitted to the ED with suspected or confirmed COVID‐19 submitted to endotracheal intubation. No patients were excluded. The primary outcome was first‐attempt intubation success, defined as successful endotracheal tube placement with the first device passed (endotracheal tube) during the first laryngoscope insertion confirmed with capnography. Secondary outcomes included the following complications: hypotension, hypoxemia, aspiration, and esophageal intubation. RESULTS: A total of 112 patients with confirmed or suspected COVID‐19 were enrolled. Median age was 61 years and 61 patients (54%) were men. The primary outcome, first‐attempt intubation success, was achieved in 82% of patients. Among the 20 patients who were not intubated on the first attempt, 75% were intubated on the second attempt and 20% on the third attempt; cricothyrotomy was performed in 1 patient. Forty‐eight (42%) patients were hypotensive and required norepinephrine immediately post‐intubation. Fifty‐eight (52%) experienced peri‐intubation hypoxemia, and 2 patients (2%) had cardiac arrest. There were no cases of failed intubation resulting in death up to 24 hours after the procedure. CONCLUSION: Emergency physicians achieve high success rates when intubating COVID19 patients, although complications are frequent. However, these findings should be considered provisional until their generalizability is assessed in their institutions and setting. Conclusion: Emergency physicians achieve high success rates when intubating COVID19 patients, although complications are frequent. However, these findings should be considered provisional until their generalizability is assessed in their institutions and setting. COVID-19, emergency physician, intubation Patients with severe coronavirus disease 2019 (COVID-19) may become critically ill with acute respiratory distress syndrome. 1 Deciding when a patient with severe COVID-19 should receive endotracheal intubation is an essential component of care. 1 As the COVID-19 pandemic spreads across the world, teams must develop airway management strategies that protect both patients and staff. 2 In many settings, emergency physicians are responsible for airway management of acutely ill COVID-19 patients presenting to the emergency department. 3 Emergency intubation of critically ill patients carries complication rates of over 40% in some series. 4 An alarmingly high percentage of patients suffer an associated cardiac arrest. [5] [6] Numerous factors may contribute to this, including hypoxemia and arterial hypotension before intubation. 6 The current scientific literature reports on the additional difficulties that COVID-19 represents to securing the airway. Among the difficulties are performing the procedure using full personal protective equipment and reports of rapidly desaturating patients. Unfortunately, early data suggest high mortality in this subset of patients. 7 ED intubation techniques for critically ill patients are largely extrapolated from operating room practice. 4 Despite insufficient or no data for many aspects, there are important differences between elective non-COVID-19 and emergency COVID-19 intubation, such as the risk to the patient of aspiration, desaturation, or hypotension and the risk of difficult laryngoscopy to medical personnel, who should wear personal protective equipment including an N95 respirator, goggles, and plastic face shields. 4,7 The objective of this study was to evaluate the first-attempt success rates and complications of endotracheal intubation of COVID-19 patients by emergency physicians. We enrolled patients consecutively admitted to the ED with suspected or confirmed COVID-19 submitted to endotracheal intubation. We considered patients with compatible clinical and computed tomography findings suspect for COVID-19. We either confirmed COVID-19 with nasopharyngeal or tracheal secretion reverse transcription polymerase chain reaction (RT-PCR). We used a Macintosh laryngoscope blade, either direct or videolaryngoscopy. No patients were excluded. Our preoxygenation strategy consisted mainly of 5 minutes of tidal volume breathing of 100% oxygen with a tightly fitted nonrebreather shut down just before removing the mask to reduce aerosolization. All patients were intubated with SpO2 >93% after preoxygenation. Also, to reduce aerosolization, we avoided the nasal cannula for apneic oxygenation. We used wave capnography to confirm all intubations. If the initial intubation attempt was unsuccessful, we used a supraglottic airway fitted with a HEPA filter, connected directly to a ventilator, or bag-valve mask, for rescue ventilation in all cases. The primary outcome was first-attempt intubation success, defined as successful endotracheal tube placement with the first device passed (endotracheal tube) during the first laryngoscope insertion confirmed with capnography. If the endotracheal tube was not inserted into the mouth during the first laryngoscope insertion, the attempt was counted as a failure. Secondary outcomes included the following complications: hypotension, hypoxemia, aspiration, and esophageal intubation. Hypotension was defined by a decrease of 30 mmHg or more in systolic blood pressure or a mean arterial pressure (MAP) <65 mmHg after the procedure. Hypoxemia was defined as an oxyhemoglobin saturation <90%. Unplanned subgroup analyses were performed for variables of clinical interest. These analyses were exploratory in nature, and a test of interaction for each subgroup was performed. Missing data were left as such; imputation was not performed. We used the 2-tailed Student's t test and Kruskal-Wallis test for parametric and non-parametric values, respectively. Data were analyzed using were in Stata 13 software (College Station, Texas, USA). The primary outcome, first-attempt intubation success, was achieved in 82% of patients. Among the 20 patients who were not intubated on the first attempt, 75% were intubated on the second attempt and 20% on the third attempt; cricothyrotomy was performed in 1 patient. The first attempt success rate was 85% in senior and 76% in junior physicians (P = 0.5). These subsequent rescue attempts used a bougie or laryngeal mask or were performed with the most experienced emergency physician available. This study has several limitations. First, as data were obtained at a single institution, findings may not be generalizable. Second, interpretation of the results of this study is limited by the small size of the cohort, the relatively short duration of follow-up, and potential missing data owing to the nature of the program, Third, there was no standardized approach to emergency intubation among attending physicians. Forth, studies show that videolaryngoscopy increases the rate of first attempt intubation in the ED; 8 however, in our study, use of the videolaryngoscope was not associated with first-attempt intubation. We believe this may have occurred because the device was first acquired during the COVID-19 pandemic and the ED staff did not have enough practice, with team members still on the learning curve. We report a cohort of 112 patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection or suspicion of COVID-19 (due to compatible clinical and radiological findings) who needed emergency intubation and analyzed success rates for firstattempt intubation by emergency physicians, as well as complications. Hypoxemia occurred in 52% patients. Patients who experienced hypoxemia received non-invasive ventilation and had a lower PaO 2 /FiO 2 ratio post-intubation, which suggests that the indication for intubation was established late, with greater pulmonary impairment. Three patients (2%) had esophageal intubation. In the first case, performed under direct laryngoscopy, this was rapidly identified because of the absence of a capnography curve; a laryngeal mask was passed, the patient was ventilated, and the second attempt at intubation was successful. In the second and third cases, performed via videolaryngoscopy, the bougie passed through the vocal cords, but resistance was encountered when passing the tube over the tube introducer, presumably from the tip catching on the arytenoid cartilages. The bougie was inadvertently removed, patients desaturated and went into cardiorespiratory arrest, which was reversed after a second attempt at orotracheal intubation. In conclusion, first-attempt intubation success was obtained in 82% of patients. Emergency intubation of COVID-19 patients is associated with a high risk of complications. Most complications occurred when the airway was managed by trainees or less experienced physicians. However, these findings should be considered provisional until their generalizability is assessed in other institutions and settings. Severe COVID-19 Pragmatic recommendations for intubating critically ill patients with suspected COVID-19 Airway management in the emergency department (The OcEAN-Study) -a prospective single centre observational cohort study Tracheal intubation in the critically ill. 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