key: cord-0869766-gml34y1p authors: Wei, Huafeng; Jiang, Bailin; Behringer, Elizabeth C.; Hofmeyr, Ross; Myatra, Sheila N.; Wong, David T.; Sullivan, Ellen P.O’; Hagberg, Carin A.; McGuire, Barry; Baker, Paul A.; Li, Jane; Pylypenko, Maksym; Ma, Wuhua; Zuo, Mingzhang; Senturk, Nuzhet M.; Klein, Uwe title: Controversies in airway management of COVID-19 patients: updated information and international expert consensus recommendations date: 2020-11-06 journal: Br J Anaesth DOI: 10.1016/j.bja.2020.10.029 sha: 22819cf151036ef8dad0b7ffa3494e1d36c2f113 doc_id: 869766 cord_uid: gml34y1p nan As knowledge and experience in the management of critically ill coronavirus disease 2019 (COVID-19) patients has increased with time, a panel of international experts convened and formulated consensus opinions regarding controversial topics in advanced airway management based on current literature. Here we summarise updated information and international expert opinion on several controversial topics concerning airway management in critically ill patients with COVID-19. Recommendations for the personal protective equipment (PPE) required during aerosol-generating procedures (AGPs), such as advanced airway management, are inconsistent amongst different countries and regions. 1e8 Two new studies report conflicting results, either supporting 9 or opposing 10 tracheal intubation and extubation as AGPs. Both studies were limited by small sample size, and used different definitions of AGPs and particle detection methods. Additional carefully designed studies are necessary to clarify the risk of aerosolised viral spread during tracheal intubation and extubation. In the interim, it is prudent to continue to consider both as AGPs. Maximal interventions to safeguard healthcare workers from cross infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) must be maintained until this question is adequately studied. Studies from China have classified levels of PPE (Fig 1) . 11 Level III has been reported to protect healthcare workers from cross infection during a variety of AGPs including tracheal intubation (Table 1) , 11, 12, 14, 15 high-flow nasal oxygen (HFNO) usage and tracheal intubation using a flexible intubating endoscope in patients with COVID-19. 15 Level II PPE, often used in other countries and regions outside China, 4,5,7 may not provide full protection from cross infection. Cross infection rates in healthcare workers range from 0% to 14.7% (Table 1) . 27, 28 The primary difference between level II and III PPE is that level III includes use of a face shield, eye goggles, water-resistant gown, and hooded coverall. This assists in avoiding exposure of skin or eyes to air and potentially aerosolised viral particles (Fig 1) . Table 2 summarises the commonly used levels of PPE around the world and the reported cross infection rates in healthcare workers. Videolaryngoscopy is the recommended approach for tracheal intubation in patients with COVID-19 in order to maximise first pass success rate and minimise exposure of healthcare workers during the procedure. 1, 12, 13 Awake tracheal intubation (ATI) has been performed successfully using flexible bronchoscopy. To date, cross infection of healthcare workers has not been reported during ATI. Therefore, ATI should be considered for management of the anticipated difficult airway, especially when tracheal intubation under general anaesthesia is considered unsafe. 14 Level III PPE should be used. It appears that the higher the level of PPE used, the better the protection against cross infection. However, adequate protection of healthcare workers is often limited by the availability of PPE during a world pandemic. It is recommended to use the highest level of PPE available in the management of patients with COVID-19, especially during performance of high-risk AGPs such as tracheal intubation, extubation, or tracheostomy. 1, 12, 17, 37 Fit testing and supervised donning and doffing of PPE remain critical steps in the avoidance of cross infection of healthcare workers. It is crucial to note that PPE must be a part of a comprehensive infection control strategy in order to be effective. Healthcare workers remain a precious resource in the fight against COVID-19. 38 Classification of personal protective equipment. 11, 12, 13 Note an N95 mask respirator or surgical mask could be used inside the powered air purifying respirator (PAPR) hood to protect against potential self-contamination during doffing of personal protective equipment (PPE). Many guidelines initially prohibited or discouraged use of high-flow nasal oxygen (HFNO) therapy in patients with COVID-19, based on the potential risks of aerosol generation and viral spread. 1 The extent of this risk remains unresolved. 36 Some studies support 29,30 use of HFNO whereas others do not ( Table 2 ). 31e33 Use of HFNO in critically ill patients with COVID-19 with hypoxic respiratory insufficiency has been examined for its potential benefit as the mortality rate of mechanically ventilated patients remains high. 39 Patients with COVID-19 with pulmonary failure but normal lung compliance appear to respond favourably to HFNO treatment, but those patients with impaired lung compliance may not derive the same benefit. 40 A cohort study from the 2009 epidemic of respiratory failure caused by influenza A found that use of HFNO reduced the need for mechanical ventilation by 45%. 34 The future use of HFNO in patients with COVID-19 will be based on its efficacy to diminish hypoxaemia, the need for mechanical ventilatory support, and mortality. Use of appropriate PPE, and supervised donning and doffing, are critical in avoiding cross infection from any AGP. Other factors, such as negative pressure rooms, high air exchange rates through the ventilation system, the ventilation system itself, and use of an anteroom, are additional important interventions to reduce the risks of cross infection. The use of HFNO for apnoeic oxygenation during laryngoscopy and tracheal intubation is recommended for selected patients with COVID-19 at high risk of hypoxaemia. 15 Another controversy associated with the use of HFNO is the concomitant use of a simple surgical mask as a means to minimise dispersion of aerosols in spontaneously breathing patients with COVID-19. A preliminary study using computational fluid dynamic simulation determined that addition of a surgical mask over a properly fitted HFNO device may be an effective option to reduce droplet deposition from exhaled gas flow. 41 A recent study of healthy volunteers evaluated aerosol production with HFNO and noninvasive positive pressure ventilation (NIPPV) compared with 6 L min À1 low-flow nasal oxygen (LFNO). 35 HFNO and LFNO were studied with and without subjects wearing a type 1 surgical face mask. Aerosol size and mass were measured at 2 and 6 ft from the patient's nasopharynx. There was no significant difference in aerosol production between HFNO, NIPPV, or LFNO. The use of a surgical mask over the HFNO device did not change aerosolised particle spread. 35 Further study is critical to confirm the safety and efficacy of the practice of applying a mask over HFNO devices. Barotrauma is a risk when HFNO is delivered simultaneously with a tightly sealed face mask, such as an anaesthesia face mask, owing to excessive delivered pressure, so this combination should be avoided. 42 There is currently no convincing evidence that HFNO increases the risk of COVID-19 cross infection to healthcare workers. Well-designed prospective studies are warranted to clarify the risk, if any, and to assess risk-reducing interventions. It is recommended that use of HFNO in patients with COVID-19 depends on the risk/benefit ratio determined by the clinician for each patient until additional information is available. Recent studies 1,2,12,43 have recommended early tracheal intubation to minimise the risk of cross infection of healthcare workers. Early tracheal intubation may obviate the need for urgent intubation and may lessen the severity of hypoxaemia and haemodynamic instability during induction of anaesthesia and tracheal intubation. Results of the combined use of noninvasive respiratory support and awake prone positioning, 44 particularly in patients with the type L (high compliance) acute respiratory distress syndrome (ARDS), are encouraging. 40 A recent report showed a significant decrease in the mortality rate of patients admitted to ICU with COVID-19. This is likely attributable to multiple factors, including increased clinical experience, rapidly developing management strategies and therapeutics and increased use of noninvasive ventilatory support such as HFNO. 45 Use of HFNO may delay tracheal intubation and mechanical ventilation, and reduce the need for admission to ICU. 36,46e48 Expert consensus This controversy regarding early vs late tracheal intubation is still evolving. 49 It is recommended that the appropriate time to intubate patients with COVID-19 may be dependent on their individual pathology and pathophysiology, the acute trajectory of their illness, in addition to their responsiveness to trials of noninvasive airway management. Level III PPE appears to provide healthcare workers with maximum protection against cross infection by aerosolised SARS-CoV-2 viral particles. The highest level of PPE should be considered in the management of patients with COVID-19, especially during performance of AGPs. Global efforts should provide adequate levels of PPE for all healthcare workers during the pandemic and uniform application of environmental controls. Use of HFNO should be considered for management of acute respiratory failure and after tracheal extubation of patients with COVID-19 as long as optimal environmental measures and protective PPE are available for healthcare workers. Noninvasive ventilation is encouraged as the first-line approach before tracheal intubation and mechanical ventilation in critically ill patients with COVID-19 with the aforementioned caveats, although further study of this approach is warranted. All authors were involved in the conception and writing of manuscript HW is a consultant of Well Lead Medical Company, Guangzhou, Guangdong, China. PAB has received travel assistance and funding for research from Fisher and Paykel Healthcare. Restrict use Santarpia and colleagues 29 Clinical observation SARS-CoV-2 The highest concentrations of virus in air were recorded during oxygenation through a nasal cannula. Loh and colleagues 30 Simulation study SARS-CoV-2 HFNO increased the dispersion distance of cough-generated droplets Support use Leung and colleagues 31 Randomised controlled crossover trial Gram-negative bacteria HFNO was not associated with increased air or contact surface contamination by bacteria in ICU patients Hui and colleagues 32 Simulation study Respiratory virus HFNO with good interface fitting was associated with limited exhaled air dispersion of virus Tran and colleagues 33 Systematic review SARS-CoV HFNO did not increase transmission risk significantly Rello and colleagues 34 Cohort study H1N1v No secondary infections in healthcare workers, nor nosocomial pneumonia occurred during HFNO therapy Miller and colleagues 35 Volunteer simulation study Aerosol production No significant difference in aerosol production between either HFNO and low-flow nasal cannula Neutrality Agarwal and colleagues 36 Systematic review SARS-CoV-2 Unknown effects of HFNO on risk of virus spreading 364 -Wei et al. 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Preliminary findings on control of dispersion of aerosols and droplets during high-velocity nasal insufflation therapy using a simple surgical mask: implications for the high-flow nasal Cannula Optiflow thrive-optiflow oxygen kit AA400, optiflow filtered nasal cannula AA001M Pragmatic recommendations for intubating critically ill patients with suspected COVID-19 Feasibility and physiological effects of prone positioning in nonintubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study Outcomes from intensive care in patients with COVID-19: a systematic review and metaanalysis of observational studies High flow nasal cannula is a good treatment option for COVID-19 Early experience of an infectious and tropical diseases unit during the coronavirus disease (COVID-19) pandemic Timing of intubation and mortality among critically ill coronavirus disease 2019 patients: a single-center cohort study We thank David Gabrielsen (Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA) for his assistance with preparing Fig 1. We thank International Airway Management Society (IAMS) for organizing two virtual meetings contributing to the international expert consensus recommendations.