Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan's Experience

Abstract

The COVID-19 outbreak has led to 80,409 diagnosed cases and 3,012 deaths in mainland China based on the data released on March 4, 2020. Approximately 3.2% of patients with COVID-19 required intubation and invasive ventilation at some point in the disease course. Providing best practices regarding intubation and ventilation for an overwhelming number of patients with COVID-19 amid an enhanced risk of cross-infection is a daunting undertaking. The authors presented the experience of caring for the critically ill patients with COVID-19 in Wuhan. It is extremely important to follow strict self-protection precautions. Timely, but not premature, intubation is crucial to counter a progressively enlarging oxygen debt despite high-flow oxygen therapy and bilevel positive airway pressure ventilation. Thorough preparation, satisfactory preoxygenation, modified rapid sequence induction, and rapid intubation using a video laryngoscope are widely used intubation strategies in Wuhan. Lung-protective ventilation, prone position ventilation, and adequate sedation and analgesia are essential components of ventilation management.

Fig. 1.

Dr. Junmei Xu is working at one of the sixteen Fang Cang hospitals in Wuhan amid the COVID-19 outbreak. Dr. Xu is a senior anesthesiologist and vice president of the Second Xiangya Hospital affiliated with Xiangya Medical School, Central South University, Changsha, Hunan, China. “Xiangya Second Hospital Xu Jun Mei” is written on his back. (Photograph by Dr. Junmei Xu.)

Fig. 2.

Screenshot of the fourth webinar with live broadcast conducted on February 29, 2020. A total of 12 intensivists and anesthesiologists (10 people from China; 2 people from the United States) discussed the experience of using extracorporeal membrane oxygenation amid the COVID-19 outbreak. Nine of the 10 Chinese experts are currently working in Wuhan and taking care of critically ill patients with COVID-19. Most of these Chinese experts stay in hotels because they came from other provinces to Wuhan to share the workload that had overwhelmed the local teams. (Photograph by Dr. Lingzhong Meng.)

Fig. 3.

A 62-yr-old male with confirmed COVID-19 required endotracheal intubation and invasive mechanical ventilation. The chest computed tomography scan suggested that, compared with that before intubation (A), the pulmonary disease had progressed 3 days after intubation (B). This progression was more likely related to the disease itself as there were no signs of ventilator-associated lung injury. (Photograph by Dr. Haibo Qiu.)

Fig. 4.

A healthy newborn was delivered from a mom with confirmed COVID-19 in Tongji Hospital in Wuhan. (Photograph by Dr. Li Wan.)

Fig. 5.

Criteria for nonoperating room intubation amid the COVID-19 outbreak. Fio₂, fraction of inspired oxygen; Pao₂, partial pressure of arterial oxygen; RR, respiratory rate.

Fig. 6.

Dr. Shanglong Yao was hospitalized after diagnosis of COVID-19. Dr. Yao is a senior anesthesiologist and former vice president of the Union Hospital affiliated with Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China. (Photograph by Dr. Shanglong Yao.)

Fig. 7.

The level III–scaled protection in Wuhan. (A) A nurse is checking and facilitating the donning process for a healthcare worker. (B) An anesthesiologist is fully equipped before entering an isolation room. (C) An anesthesiologist is wearing a head cover that is connected to a positive pressure ventilation system, which makes the full-coverage level III–scaled protection much more tolerable. (Photograph by Dr. Li Wan.)

Fig. 8.

Anesthesiologists performing endotracheal intubation in patients with COVID-19. (A) Three anesthesiologists wearing level III–scaled protection were performing endotracheal intubation. (B) Only one anesthesiologist was performing endotracheal intubation. (Photograph by Dr. Li Wan.)

Fig. 9.

Prone position ventilation for critically ill patients with COVID-19. (A) An intubated patient turned prone; (B) an intubated patient with extracorporeal membrane oxygenation support turned prone. (Photograph by Drs. Haibo Qiu and Chun Pan.)