key: cord-0958479-ggj3l4j9
authors: Raithel, Stephen; Fields, Kara G.; Wu, Yiran; Yao, Dongdong
title: Adoption of airway management guidelines during COVID-19 pandemic improved endotracheal intubation success
date: 2021-10-13
journal: J Clin Anesth
DOI: 10.1016/j.jclinane.2021.110556
sha: 9c67f9dba837530460693b332aa9bb19c389b350
doc_id: 958479
cord_uid: ggj3l4j9

nan

To the editor, Since the emergence of the novel COVID-19 virus in November 2019, there has been significant concern for occupational risk to anesthesiologists involved in airway management in the peri-operative period. As even presymptomatic patient may transmit the virus [1] , multiple professional societies issued recommendations for safe endotracheal intubation for all peri-operative patients [2] [3] [4] [5] [6] . In our health system, the implemented guidelines stated that all patients should undergo rapid-sequence intubation, avoidance of mask ventilation, universal video laryngoscope use, and intubation by the most experienced provider. These changes were instituted for the safety of the airway management teams, and yet the effect on patient outcomes, such as safe and effective intubations, is unknown. We investigated how this rapid and large-scale shift in airway management practice in a real-world setting impacted the rate of first-time successful intubation in our health system. Institutional Review Board exemption for this project was granted by the Brigham and Women's Hospital IRB Committee. We analyzed surgeries under general endotracheal anesthesia from the time that our health system adopted airway management guidelines on 3/23/2020, until the time when our health system started scheduling more elective cases on 5/21/2020 (n=3,344); we compared this to a cohort of surgeries occurring under general endotracheal anesthesia from the year prior (n= 36,789). Cases were identified through query of our electronic health record in retrospective fashion. Surgical cases were excluded from consideration if the patients were less than 18 years old, if there were multiple successful intubations documented for the case, ASA status of 6 or ASA status was missing, the number of attempts until successful intubation was missing, or if the urgency of the case was not known. Surgeries that took place at hospitals in our health system with less than 100 cases with recorded urgency after the initiation of airway guidelines were excluded.

Multivariable segmented mixed effects logistic regression was used to estimate the association between airway management guideline adoption and the odds of first-time intubation success, video laryngoscopy use, rapid sequence intubation, use of mask ventilation, and attending-only intubation adjusting for hospital, age, sex, emergent/urgent vs. non-urgent/elective surgery, and ASA class. Segmented regression was used to account for preguideline levels and trends in outcomes, and mixed effects models with random intercepts and first-order autoregressive correlation structure were used to account for the correlation between multiple surgeries on the same patient. A p-value < 0.05 was considered significant.

After airway management guidelines were set, anesthesia providers in our health system adhered to most of these guidelines. Specifically, video laryngoscopy use increased (Odds Ratio 6.01 [95% C.I. 5.09 -7.11], p<0.001, Figure   1A ), as did use of rapid sequence intubation (OR 11.21 [9.36 -13 .42], p<0.001, Figure 1B ). Mask ventilation prior to intubation decreased (OR 0.04 [0.03 -0.05], p<0.001, Figure 1C ). However, there was no change in the number of intubations done exclusively by attending anesthesiologists (Figure 1D ). While we think the relationship between increased use of video laryngoscopy was causal to our increased odds of first-attempt intubation success, we were unable to directly test this. Video laryngoscopy is most likely to be beneficial for trainees in helping secure first-attempt intubation success [7, 8] . Indeed, our data shows that trainees had increased odds of first-attempt intubation after our airway management guidelines were adopted (OR 1.72 [1.2, 2.47]), but this was not the case for attending only intubations (OR 0.82 [0.41, 1.66]). We speculate that the attending subgroup did not have increased odds of first-attempt intubation success after the pandemic guidelines were issued due to a mixture of more experience with laryngoscopy as well as more expert judgement in when video laryngoscopy was needed prior to the pandemic airway guidelines. Previous study showed that 35.6% of anesthesia providers (both trainees and attending anesthesiologists) would attempt direct laryngoscopy first and use video laryngoscopy (or fiberoptic intubation) as their back-up device for anticipated difficult intubation [9] . If video laryngoscopy use more generally is responsible for the increased odds of first attempt intubation success, further 

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