key: cord-0994085-4ncyy9ru authors: Sethi, R.; Sethi, S. title: Emergency tracheal intubation in the COVID-19 context: is it any different? Comment on Br J Anaesth 2020, xxx date: 2020-06-03 journal: Br J Anaesth DOI: 10.1016/j.bja.2020.05.045 sha: 990b0d3ff07160fd36970542246f10c79b5900ee doc_id: 994085 cord_uid: 4ncyy9ru nan The low incidence of hypotension (7.9%) prior to securing the airway reflects timely intervention by the operators. However, nearly a quarter of the patients were tachycardic, implying potentially significant haemodynamic derangement. However, we failed to understand the substantial number of unconscious patients (12.9%). Was it haemodynamic compromise leading to impaired cerebral perfusion, or were there any other contributory factors (with metabolic derangement) responsible? Tracheal intubation was facilitated in all cases by 'modified' rapid sequence induction (RSI). Mask ventilation after induction was performed in the majority (93.1 %) of patients. Historically, manual ventilation before tracheal intubation was considered an integral component of RSI. 4, 5 Wylie proposed the concept of 'not inflating' the patient's lungs with oxygen until tracheal intubation had been accomplished in 1963. 6 This view was 3 subsequently reinforced by Stevens in 1964. 7 Both these authors hypothesized that positive pressure ventilation before intubation increases the risk of gastric inflation and the potential for regurgitation. 6, 7 Incorporation of these changes into practice led to the origin of the concept of 'modified' RSI. Thus, we believe that the authors performed 'traditional' RSI and not the 'modified' RSI technique. Manual ventilation in this cohort of patients could be counterproductive for three reasons. Firstly, it might increase the risk for regurgitation and aspiration in patients who necessarily could not be ensured to be fasting. Secondly, the underlying condition was necessarily due to a shunt or ventilation-perfusion (VQ) mismatch. Administration of supplemental oxygen would not increase the arterial partial pressure of oxygen in the presence of a shunt or VQ mismatch. The operators had done their best by ensuring thorough pre-oxygenation with 100% oxygen in all patients. Bag-mask ventilation would not have contributed anything more to enhance oxygenation apart from losing critical time. Lastly, and most importantly, bag-mask ventilation is an aerosol-generating procedure. 8, 9 In light of this, its use in the current context should consider the risk-benefit ratio, keeping in mind the safety of all operators involved. The same rationale applies to the high (70.8%) number of patients subjected to non-invasive ventilation. Given that noninvasive ventilation is also considered an aerosol-generating procedure, 9 we feel that restraint should have been exercised in its implementation in the current context. Protection of healthcare workers is not just about protective equipment; it encompasses all the principles of infection prevention and control. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomized controlled trial Fluid management in Acute Respiratory Distress Syndrome: A narrative review Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia Induction of anaesthesia in the foot-down position for patients with a full stomach The use of muscle relaxants at the induction of anaesthesia of patients with a full stomach Anaesthetic problems of intestinal obstruction in adults Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore Outbreak of a new coronavirus: what anaesthetists should know [Epub ahead of print Novel coronavirus (2019-nCoV) technical guidance: infection prevention and control The authors have no conflicts of interest ot declare.