I sincerely thank the authors for describing an experienced-based technique to support the safe tracheal intubation of patients with suspected or confirmed coronavirus disease (COVID-19).1 Their suggestion to use a delayed sequence technique in selected patients is a valuable addition to the “Recommendations for endotracheal intubation of COVID-19 patients.”2 Specifically, they suggest that agitated and uncooperative patients be sedated with ketamine during the preoxygenation phase, to gain their cooperation while minimizing the risk of respiratory depression and cardiovascular instability.
The authors describe a difficult and high-stakes scenario. An agitated and uncooperative patient with COVID-19 represents a considerable safety risk to the airway management team. Dislodgement of or damage to personal protective equipment can expose health care providers to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus. In addition, movement of glasses, goggles, or a face shield can lead to fogging or an obstructed view, which makes tracheal intubation more difficult. Thus, it may be desirable to optimize conditions by sedating certain patients before tracheal intubation.
Additional suggestions from others include using a 2-handed technique with the hands in the VE position when using a self-inflating bag-valve-mask device during preoxygenation,3 cross-checking team members’ personal protective equipment (particularly when managing agitated patients), having all needed materials prepared in advance, and knowing the patients’ code status.4
I applaud the authors and others for sharing their lived experiences as we learn together to support patients and each other during the COVID-19 pandemic.
Beverley A. Orser, MD, PhD
Departments of Anesthesiology and Pain Medicine and Physiology
University of Toronto
Toronto, Ontario, Canada
Department of Anesthesia
Sunnybrook Health Sciences Centre
Toronto, Ontario, Canada
1. Castro de Oliveira BM, de Souza RLPAdvantages of delayed sequence intubation in selected patients with COVID-19. Anesth Analg. 2020;131:e133–e134.
2. Orser BARecommendations for endotracheal intubation of COVID-19 patients. Anesth Analg. 2020;130:1109–1110.
3. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs AConsensus guidelines for managing the airway in patients with COVID-19. Anaesthesia. 2020;75:785–799.
4. Duggan LV, Mastoras G, Bryson GLTracheal intubation of patients with COVID-19. CMAJ. 2020 May 1 [Epub ahead of print].