key: cord-1049046-ip5jivfe authors: Sanfilippo, Filippo; Tigano, Stefano; Palumbo, Gaetano J.; Astuto, Marinella; Murabito, Paolo title: Systematic review of simulated airway management whilst wearing personal protective equipment() date: 2020-06-13 journal: Br J Anaesth DOI: 10.1016/j.bja.2020.06.011 sha: 448d045cfd5fdcac919f2057f05f3a3902388c20 doc_id: 1049046 cord_uid: ip5jivfe nan (COVID-19) in 188 countries/regions with over 400,000 deaths 1 . Around 2.3% of COVID-19 patients require tracheal intubation 2 . Since COVID-19 is a highly contagious disease, tracheal intubation is considered a high-risk procedure. A greater risk of contagion for healthcare workers performing tracheal intubation was described during the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic 3, 4 and was confirmed by systematic review 5 . Several recommendations [6] [7] [8] have been published providing suggestions to reduce the risk of viral transmission with airway management during COVID-19. Most recommendations agree on: planning ahead; wearing full personal protective equipment (PPE); involvement of senior staff; exposing the fewest possible healthcare workers; adequate pre-oxygenation; avoiding manual bag-mask ventilation; rapid-sequence induction whenever possible; use of videolaryngoscopy, ideally with a distant screen display that allows distancing of operators from the patient's airway; and availability of a second-generation supraglottic airway device. These recommendations are mostly based on experience acquired during present 7 and previous 9 pandemics, with no supporting evidence from controlled studies. In order to evaluate the current evidence on best practices for tracheal intubation whilst wearing PPE, we conducted a systematic review of the literature looking at manikin-based simulation studies investigating airway management under the constraints of wearing PPE. We systematically searched the MedLine database with the last update on June 1, 2020; the MESH terms "airway", "simulat*" and "manikin" were combined. We included studies investigating tracheal intubation or supraglottic airway device insertion in simulated adult scenarios. The outcomes of interests were the success rate and time-to-intubation (or correct placement). We applied the following restrictions: only articles providing an abstract and published in the English language were included. Two pairs of assessors Seven studies were included in the analysis [10] [11] [12] [13] [14] [15] [16] . Table 1 shows study characteristics and most relevant findings. Five studies investigated only intubation 11, 12, [14] [15] [16] , one evaluated only supraglottic airway device placement 10 , and one included both intubation, supraglottic airway device placement and cricothyroidotomy 13 . The participants in these studies ranged from paramedic students (with no airway management experience 10,11 ) to anaesthesiologists 13 ; the number of participants ranged from 16 16 to 66 11 . The type of PPE worn also varied greatly. Six studies evaluated tracheal intubation with direct laryngoscopy (in some cases with stylet or bougie 11 ), with time-to-intubation ranging from 24 to 29 s, apart from one study whose participants were paramedic students reporting longer times (> 50 s 11 In two studies the videolaryngoscopes Pentax-AWS ® and Glidescope ® performed better than direct laryngoscopy both for time-to-intubation and success rate 14, 15 . In one study both KingVision ® and Glidescope ® had better success rate than direct laryngoscopy but longer time-to-intubation 12 . In the remaining two studies, Airtraq ® had poorer performances than direct laryngoscopy both in terms of success rate and time to success 11, 13 . Two studies evaluated the intubating laryngeal mask airway 11, 16 with divergent findings in time-to-intubation (one study included paramedic students 11 and one involved emergency medicine residents with prior airway experience 16 ). The only study evaluating the positioning of six supraglottic airway devices for ventilation found that i-gel ® had the best performances, with 100% success rate within 60 s and the shortest time-toplacement (19 s). Furthermore, i-gel ® was the only device where successful placement was in some cases reported within 15 s 10 . Our systematic review highlights a significant knowledge gap regarding airway management under simulated conditions of wearing PPE. We found high heterogeneity in study design, devices investigated, procedure performed and outcomes analysed; therefore, it is difficult to draw solid conclusions. We believe there is urgent need for comparative studies investigating strategies for airway management in situations with high-risk of contagion such as during a respiratory infection pandemic. Interestingly, we found only one study performed with anaesthesiologists as subjects. 13 Two studies have confirmed that even staff with prior experience took significantly longer to achieve successful airway management whilst wearing PPE compared to not wearing it 17, 18 . Clinical studies with risk of contamination with highly infectious pathogens would be unethical, so simulation studies should be encouraged for two main reasons. Firstly, healthcare workers participating in simulation whilst wearing PPE may gain more confidence in managing these difficult scenarios. Moreover, we suggest that simulation of airway management whilst wearing PPE should become part of the training curriculums in the future. Secondly, comparative studies may evaluate different aspects, comparing the techniques/approaches with the highest success rate and those with fastest achievement of goals. As an example, in one study videolaryngoscopy had a better success rate but took longer times to complete the procedure. Comparative studies may produce different results than those expected by theoretical models . For example, one study 15 found that Glidescope ® (un-channelled, distant monitor) had a 6-s slower time-to-intubation than KingVision ® (channelled, monitor on scope). In theory, one would expect a more comfortable and easier visualization of vocal cords with the use of a videolaryngoscope with a distant screen whilst wearing PPE. Our systematic review found few studies on airway management by operators wearing PPE. The large heterogeneity of these studies does not warrant a quantitative analysis, but it suggests an urgent need to design large simulation studies with personnel potentially exposed to aerosol-generating procedures such as airway management. The authors have no conflicts to declare. China Medical Treatment Expert Group for COVID-19,(2020) Clinical Characteristics of Coronavirus Disease 2019 in China SARS safety and science/La science et les mesures de sécurité contre le SRAS SARS among critical care nurses Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review 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 Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations Recommendations for Endotracheal Intubation of COVID-19 Patients Intubation of SARS patients: infection and perspectives of healthcare workers Insertion of six different supraglottic airway devices whilst wearing chemical, biological, radiation, nuclear-personal protective equipment: a manikin study Comparison of six different intubation aids for use while wearing CBRN-PPE: a manikin study Airway Management in Disaster Response: A Manikin Study Comparing Direct and Video Laryngoscopy for Endotracheal Intubation by Prehospital Providers in Level C Personal Protective Equipment Emergency Airway Management in a Simulation of Highly Contagious Isolated Patients: Both Isolation Strategy and Device Type Matter 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 Intubating laryngeal mask airway versus laryngoscopy and endotracheal intubation in the nuclear, biological, and chemical environment Practicality of performing medical procedures in chemical protective ensembles Comparison of intubation devices in level C personal protective equipment: A cadaveric study We would like to thank Valeria La Rosa and Francesco Oliveri from our Department of Anaesthesia and Intensive Care for their support during the assessment of abstracts. We are also grateful to Ruth Halstead (DISUM; Department of Humanities, University of Catania, Italy) and Carlos M. Corredor (Bart's Heart Centre, London, UK) for their help in critically revising the manuscript for language.