Skip to main content

Main menu

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2021
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2021
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
Practice

Tracheal intubation in patients with COVID-19

Laura V. Duggan, George Mastoras and Gregory L. Bryson
CMAJ June 01, 2020 192 (22) E607; DOI: https://doi.org/10.1503/cmaj.200650
Laura V. Duggan
Departments of Anesthesiology and Pain Medicine (Duggan, Bryson), and Emergency Medicine (Mastoras), University of Ottawa; Clinical Epidemiology Program (Bryson), Ottawa Hospital Research Institute, Ottawa, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
George Mastoras
Departments of Anesthesiology and Pain Medicine (Duggan, Bryson), and Emergency Medicine (Mastoras), University of Ottawa; Clinical Epidemiology Program (Bryson), Ottawa Hospital Research Institute, Ottawa, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Gregory L. Bryson
Departments of Anesthesiology and Pain Medicine (Duggan, Bryson), and Emergency Medicine (Mastoras), University of Ottawa; Clinical Epidemiology Program (Bryson), Ottawa Hospital Research Institute, Ottawa, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Related Content
  • Metrics
  • Responses
  • PDF
Loading

Prepare outside the patient’s room: assign team roles, check equipment and review the airway strategy

Limit the number of in-room team members depending on the patient’s condition and delegate an outside-room “runner” to provide additional outside-room equipment and medications. The airway manager should be experienced enough to achieve greater than 85% first-pass success for endotracheal intubation.1 The airway strategy includes preoxygenation, positioning, endotracheal intubation and a clear plan for rescue oxygenation.2 Use a checklist to confirm in-room versus immediately available outside-room equipment and medications. Prepare all in-room materials in an airway box or go bag (Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.200650/-/DC1). Patients with coronavirus disease 2019 (COVID-19) are “physiologically difficult.”2 Ensure that the patient’s code status is known and the crash cart is available.2

Don personal protective equipment (PPE) and cross-check team members3

During the severe acute respiratory syndrome epidemic, clinicians performing endotracheal intubation acquired infection at a 6-fold greater rate than their colleagues.4 Endotracheal intubation is a high-risk, aerosol-generating medical procedure that requires high-risk PPE, including an N95 respirator or equivalent.3 Speaking may become muffled and communication more difficult once PPE is donned.3

Videolaryngoscopy may have benefits over direct laryngoscopy

Videolaryngoscopy has a high first-pass success rate for experienced airway managers. A separate large screen allows the airway team to share laryngoscopy imaging and offers a greater team-to-airway distance.5

During intubation: anticipate rapid oxygen desaturation and associated emergencies

Use local protocols to guide intubation. Preoxygenate in a 30° head-up position. Ketamine may maintain cardiovascular stability compared with other induction agents.2 Have inotropes and vasopressors in line or immediately available. Use high-dose rocuronium (1.2–1.5 mg/kg) and ensure full neuromuscular blockade before attempting endotracheal intubation. 2 Owing to aerosol generation, avoid bag–valve–mask ventilation despite desaturation.2,4 Use a styleted endotracheal tube and avoid floppy bougies to minimize contamination. After intubation, place a viral filter on the endotracheal tube and inflate the endotracheal tube cuff to ensure no leak occurs with positive-pressure ventilation.2 Waveform capnography is invaluable for confirmation of endotracheal intubation, return of spontaneous circulation in cardiac arrest and circuit disconnection.2 Should circuit disconnection occur, clamp the endotracheal tube.2 Two emergencies may occur: “cannot intubate, cannot oxygenate” and cardiac arrest. Rescue oxygenation includes supraglottic device placement and endotracheal tube cricothyrotomy using a scalpel–bougie 6.0.

Removing PPE carries a high-risk of self-contamination

It is difficult to detect self-contamination.3 Use a doffing checklist, read each step aloud and remove PPE as directed by a spotter.3 Interruptions during this process should be minimized.

Footnotes

  • Competing interests: Laura Duggan is co-founder of The Airway App (www.airwaycollaboration.org/), a smartphone app for reporting outcomes of airway management, including for COVID-19. Gregory Bryson is the Deputy Editor-in-Chief of the Canadian Journal of Anesthesia for which he receives support from the Canadian Anesthesiologists’ Society. No other competing interests were declared.

  • This article has been peer reviewed.

References

  1. ↵
    1. Park L,
    2. Zeng I,
    3. Brainard A
    . Systematic review and meta-analysis of first-pass success rates in emergency department intubation: creating a benchmark for emergency airway care. Emerg Med Australas 2017;29:40–7.
    OpenUrl
  2. ↵
    1. Cook TM,
    2. El-Boghdadly K,
    3. McGuire B,
    4. et al
    . Consensus guidelines for managing the airway in patients with COVID-19. Anaesthesia 2020 Mar. 27 [Epub ahead of print]. doi: 10.1111/anae.15054.
    OpenUrlCrossRef
  3. ↵
    1. Lockhart SL,
    2. Duggan LV,
    3. Wax RS,
    4. et al
    . Personal protective equipment (PPE) for both anesthesiologists and other airway managers: principles and practice during the COVID-19 pandemic. Can J Anesth 2020 Apr. 23 [Epub ahead of print]. doi: 10.1007/s12630-020-01673-w.
    OpenUrlCrossRef
  4. ↵
    1. Tran K,
    2. Cimon K,
    3. Severn M,
    4. et al
    . Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One 2012;7:e35797.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Hall D,
    2. Steel A,
    3. Heij R,
    4. et al
    . Videolaryngoscopy increases ‘mouth-to-mouth’ distance compared with direct laryngoscopy. Anaesthesia 2020 Mar. 27 [Epub ahead of print]. doi: 10.1111/anae.15047.
    OpenUrlCrossRef
PreviousNext
Back to top

In this issue

Canadian Medical Association Journal: 192 (22)
CMAJ
Vol. 192, Issue 22
1 Jun 2020
  • Table of Contents
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Tracheal intubation in patients with COVID-19
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Tracheal intubation in patients with COVID-19
Laura V. Duggan, George Mastoras, Gregory L. Bryson
CMAJ Jun 2020, 192 (22) E607; DOI: 10.1503/cmaj.200650

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
Tracheal intubation in patients with COVID-19
Laura V. Duggan, George Mastoras, Gregory L. Bryson
CMAJ Jun 2020, 192 (22) E607; DOI: 10.1503/cmaj.200650
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Prepare outside the patient’s room: assign team roles, check equipment and review the airway strategy
    • Don personal protective equipment (PPE) and cross-check team members3
    • Videolaryngoscopy may have benefits over direct laryngoscopy
    • During intubation: anticipate rapid oxygen desaturation and associated emergencies
    • Removing PPE carries a high-risk of self-contamination
    • Footnotes
    • References
  • Figures & Tables
  • Related Content
  • Responses
  • Metrics
  • PDF

Related Articles

  • Intubation endotrachéale chez les patients atteints de COVID-19
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Asymptomatic hydrocephalus
  • How to use antihistamines
  • Pseudoaneurysm of the brachial artery in a patient who uses intravenous drugs
Show more Practice

Similar Articles

Collections

  • Sections
    • Cases
  • Topics
    • Respiratory medicine
    • Infectious diseases: COVID-19
    • Emergency medicine
    • Anesthesia & analgesia
    • Critical & intensive care

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions

Copyright 2021, Joule Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

To receive any of the resources on this site in an accessible format, please contact us at cmajgroup@cmaj.ca.

Powered by HighWire