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Awake tracheal intubation during the COVID‐19 pandemic – an aerosol‐minimising approach

Awake tracheal intubation during the COVID‐19 pandemic – an aerosol‐minimising approach We recently needed to perform awake tracheal intubation (ATI) for a patient undergoing urgent maxillofacial surgery at our secondary hospital. During the coronavirus disease 2019 (COVID‐19) pandemic all maxillofacial surgery patients are treated as suspected COVID‐19 and ATI is widely regarded as high‐risk for aerosol generation. We sought early multidisciplinary input and were informed by Ahmad et al.’s recent case report [1].Our operating theatres have positive‐pressure airflow. Negative‐pressure rooms are available elsewhere in the hospital but we felt managing a difficult airway in an unfamiliar environment posed significant risk. Our available personal protective equipment comprised a disposable gown; N95 mask; goggles; full‐face shield; and double gloves. We administered glycopyrrolate intravenously and used a topicalisation process designed to minimise aerosol generation: Pacey’s paste to the posterior tongue [2]; lidocaine 10% sprays to the oropharynx; lidocaine 4% via a mucosal atomiser device; and internal superior laryngeal nerve blocks using lidocaine 4%‐soaked gauze and Jackson laryngeal forceps [3]. Following Difficult Airway Society guidelines [4], the total dose of lidocaine administered was < 9 mg.kg‐1 (lean body weight) and a second anaesthetist administered remifentanil for conscious sedation by target‐controlled infusion at 2 ng.ml−1. Oxygen 4 l.min−1 was given via Hudson mask with end‐tidal carbon dioxide monitoring and a cut‐out permitting oral access. Excellent topicalisation was achieved. First‐pass orotracheal intubation was performed without complication using a disposable Ambu® aScope™ 4 Broncho size Regular (Ambu A/S, Ballerup, Denmark). A Shiley™ Lo‐Contour flexible reinforced endotracheal tube of size 7.0 mm (Covidien Ireland Limited, Tullamore, Ireland) was used and the tracheal tube cuff was gently inflated before the induction of anaesthesia.We describe an effective aerosol‐minimising approach to ATI. This process varied from our usual practise which typically includes high‐flow nasal oxygen, the EZ‐100m™ disposable atomiser (Alcove Medical inc., Houston, TX, USA) nasotracheal intubation and cuff inflation after induction of anaesthesia – these were avoided due COVID‐19 aerosolisation concerns.AcknowledgementsPublished with the written consent of the patient. No external funding or competing interests declared.ReferencesAhmad I, Wade S, Langdon A, Chamarette H, Walsh M, Surda P. Awake tracheal intubation in a suspected COVID‐19 patient with critical airway obstruction. Anaesthesia Reports. 2020; 8: 28–31.Gil KSL, Diemunsch PA. Flexible scope intubation techniques. In: Hagberg CA, Artime CA, Aziz MF, eds. Hagberg and Benumof’s Airway Management, 4th edn. Philadelphia, PA: Elsevier, 2018: 443.Morris IR. Preparation for awake intubation. In: Hung O, Murphy MF, eds. Hung’s Difficult and Failed Airway Management, 3rd edn. New York: McGraw‐Hill, 2017: 70.Ahmad I, El‐Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2020; 75: 509–28. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Anaesthesia Reports Wiley

Awake tracheal intubation during the COVID‐19 pandemic – an aerosol‐minimising approach

Phipps, S. J.; Scott, A. C.; Legge, C. E.
Anaesthesia Reports , Volume 8 (2) – Jul 1, 2020
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Wiley
Copyright
2020 © Association of Anaesthetists
eISSN
2637-3726
DOI
10.1002/anr3.12057
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Abstract

We recently needed to perform awake tracheal intubation (ATI) for a patient undergoing urgent maxillofacial surgery at our secondary hospital. During the coronavirus disease 2019 (COVID‐19) pandemic all maxillofacial surgery patients are treated as suspected COVID‐19 and ATI is widely regarded as high‐risk for aerosol generation. We sought early multidisciplinary input and were informed by Ahmad et al.’s recent case report [1].Our operating theatres have positive‐pressure airflow. Negative‐pressure rooms are available elsewhere in the hospital but we felt managing a difficult airway in an unfamiliar environment posed significant risk. Our available personal protective equipment comprised a disposable gown; N95 mask; goggles; full‐face shield; and double gloves. We administered glycopyrrolate intravenously and used a topicalisation process designed to minimise aerosol generation: Pacey’s paste to the posterior tongue [2]; lidocaine 10% sprays to the oropharynx; lidocaine 4% via a mucosal atomiser device; and internal superior laryngeal nerve blocks using lidocaine 4%‐soaked gauze and Jackson laryngeal forceps [3]. Following Difficult Airway Society guidelines [4], the total dose of lidocaine administered was < 9 mg.kg‐1 (lean body weight) and a second anaesthetist administered remifentanil for conscious sedation by target‐controlled infusion at 2 ng.ml−1. Oxygen 4 l.min−1 was given via Hudson mask with end‐tidal carbon dioxide monitoring and a cut‐out permitting oral access. Excellent topicalisation was achieved. First‐pass orotracheal intubation was performed without complication using a disposable Ambu® aScope™ 4 Broncho size Regular (Ambu A/S, Ballerup, Denmark). A Shiley™ Lo‐Contour flexible reinforced endotracheal tube of size 7.0 mm (Covidien Ireland Limited, Tullamore, Ireland) was used and the tracheal tube cuff was gently inflated before the induction of anaesthesia.We describe an effective aerosol‐minimising approach to ATI. This process varied from our usual practise which typically includes high‐flow nasal oxygen, the EZ‐100m™ disposable atomiser (Alcove Medical inc., Houston, TX, USA) nasotracheal intubation and cuff inflation after induction of anaesthesia – these were avoided due COVID‐19 aerosolisation concerns.AcknowledgementsPublished with the written consent of the patient. No external funding or competing interests declared.ReferencesAhmad I, Wade S, Langdon A, Chamarette H, Walsh M, Surda P. Awake tracheal intubation in a suspected COVID‐19 patient with critical airway obstruction. Anaesthesia Reports. 2020; 8: 28–31.Gil KSL, Diemunsch PA. Flexible scope intubation techniques. In: Hagberg CA, Artime CA, Aziz MF, eds. Hagberg and Benumof’s Airway Management, 4th edn. Philadelphia, PA: Elsevier, 2018: 443.Morris IR. Preparation for awake intubation. In: Hung O, Murphy MF, eds. Hung’s Difficult and Failed Airway Management, 3rd edn. New York: McGraw‐Hill, 2017: 70.Ahmad I, El‐Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2020; 75: 509–28.

Journal

Anaesthesia Reports – Wiley

Published: Jul 1, 2020

References

  • Awake tracheal intubation in a suspected COVID‐19 patient with critical airway obstruction
    Ahmad, I; Wade, S; Langdon, A; Chamarette, H; Walsh, M; Surda, P
  • Hagberg and Benumof’s Airway Management
    Gil, KSL; Diemunsch, PA
  • Hung’s Difficult and Failed Airway Management
    Morris, IR
  • Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults
    Ahmad, I; El‐Boghdadly, K; Bhagrath, R