To the Editor
We read with great interest the article by Lopez et al,1 and we would like to add some comments to their excellent study.
Coronavirus disease 2019 (COVID-19) patients pose unique challenges for airway management. Anesthesiologists are called to deal with the risk of infection; with difficulty in airway instrumentation and communication due to personal protective equipment (PPE); and last, but not least, with critical patients with unique desaturation patterns and pulmonary dysfunction.2
As from our experience, we strongly support the use of simulation and training, local protocols, and checklists—given the new settings we are called to deal in—emphasizing the importance of planning and preprocedural team briefing with meticulous preparation of alternative plans. Keeping protection of health care providers as first mandatory condition, with full airborne-level PPE for airway management team.2
As from the Wuhan experience, we also support the creation of “intubation teams,”1–3 but our first-line involvement with COVID-19 patients supports the idea to create “intubation spots” rather than “intubation kits.”
Using a preassembled kit might result in lack of unplanned materials or much commonly in waste of not used materials (ie, alternative size tracheal tubes which would be considered “infected” once opened bedside). As a side remark, we notice that the intubation kit as proposed by Lopez et al1 seems to be missing airway introducer, supraglottic airway device, and cricothyrotomy set.
In our recommendations,2 we suggest using a videolaryngoscope coupled with endotracheal tube preassembled on a bougie to maximize first-pass success; we address to early use of intubable second-generation supraglottic airway device (SAD) after second failed laryngoscopic attempt and to early cricothyrotomy should the team be aware of no alternatives left, independently on saturation values. Finally, we advise integration of the intubation kit with a capnography monitor or ultrasound machine for tube position confirmation, given the difficulty of visual and auscultatory confirmation with donned PPE, apart from well-known limitations of these techniques.2
For these reasons, we rather suggest preparing a fully equipped and double-checked airway cart—including disposable flexible videoendoscopic system, monitors, defibrillator, and high-efficiency closed system suction unit and anesthetic medications—to be left in place in specific isolated/negative pressure “intubation spots.” This way, the intubation team would act in a familiar and safe environment where COVID-19 patient should be transported before airway instrumentation.
We understand this approach could be somewhat logistically challenging, implicating that the patient should be moved on spontaneous breathing or noninvasive ventilation (NIV) support with consequential risk of environmental contamination (given that the intubated patient on his filtered breathing circuit represents a “closed system” with minimal viral spread).
On the other hand, as the patient has to be moved toward intensive care unit (ICU) or high level of care beds if he/she is not already there anyways, we believe that the choice of intubation spots might increase either patients’ and airway team’s safety. It would also somewhat address the team to adequate preliminary planning and briefing, slowing down an evolving situation. Finally, it could also represent a further mean to optimize the “oxygenation management” of COVID-19 patients.
Our experience2 has shown that once the symptomatic hospitalized COVID-19 patient fails the so-called NIV-trial, early (“anticipated”) elective intubation should be preferred to minimize clinical risks for the patient and infective and nontechnical issues for the intubating team. Acting in an elective setting seems to be the safer approach, and time will show if this also has implications on outcome, as of earlier oxygenation optimization and minimizing the risk of patient self-induced lung injury (P-SILI) due to noninvasive ventilation in high-compliance lungs.4
Such an organization implies an integrated approach with the need of a COVID-19 team regularly checking the critical-care beds availability on one side and the evolving patients in hospital wards including “emergency cases” on the other. Preliminary identification and setting of hot (airway) spots (ie, emergency department, infectious diseases ward, ICU) and adoption of early warning scores (better if COVID-19 modified-early warning scores (EWS), actually under test—unpublished data) would represent a great benefit.
Since the ancient teaching of Sun Tzu's Art of War,5 and up to the military lessons from Napoleone Bonaparte,6 knowing the environment and maximizing its benefits is one of the keys of success in a battle. We need many to fight in the war against the COVID-19 pandemic, so it is better if we move them into well-known, familiar, and bullet-proof territories.
Massimiliano Sorbello, MD
Department of Emergency, Anesthesia and Intensive Care
Policlinico Vittorio Emanuele San Marco University Hospital
Gianluigi Morello, MD
Department of Anaesthesia
Azienda di Rilievo Nazionale ad Alta Specializzazione - Garibaldi
Sergio Pintaudi, MD
Anesthesia and Intensive Care
Azienda di Rilievo Nazionale ad Alta Specializzazione - Garibaldi
Rita Cataldo, MD
Anesthesia Intensive Care and Pain Medicine
Department of Medicine
Bio-Medico of Rome
1. Lopez RA, Anthony A, Zuo L, Enomoto TM, Aziz MFYour COVID-19 intubation kit. Anesth Analg. 2020;131:e28–e30.
2. Sorbello M, El-Boghdadly K, Di Giacinto I, Cataldo R, Esposito C, Falcetta S, et albehalf of The Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) Airway Research Group, and The European Airway Management Society. The Italian coronavirus disease 2019 outbreak: experiences and recommendations from clinical practice. Anaesthesia. 2020;75:724–732.
3. Manping Y, Hailong D, Zhihong LRole of anaesthesiologists during the coronavirus disease 2019 outbreak in China. Br J Anaesth. 2020 April 9 [Epub ahead of print].
4. Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, et al.COVID-19 pneumonia: different respiratory treatment for different phenotypes? Intensive Care Med. 2020 April 14 [Epub ahead of print].
5. Ancientmilitary.com. The Art Of War By Sun Tzu Online Book. 2015. Available at: http://www.ancientmilitary.com/the-art-of-war-online.htm
. Accessed April 19, 2020.
6. Esposito VJMilitary History and Atlas of Napoleonic Wars. 1994.London, UK: Greenhill Books;