Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations

Abstract

Tracheal intubation in coronavirus disease 2019 (COVID-19) patients creates a risk to physiologically compromised patients and to attending healthcare providers. Clinical information on airway management and expert recommendations in these patients are urgently needed. By analysing a two-centre retrospective observational case series from Wuhan, China, a panel of international airway management experts discussed the results and formulated consensus recommendations for the management of tracheal intubation in COVID-19 patients. Of 202 COVID-19 patients undergoing emergency tracheal intubation, most were males (n=136; 67.3%) and aged 65 yr or more (n=128; 63.4%). Most patients (n=152; 75.2%) were hypoxaemic (Sao₂ <90%) before intubation. Personal protective equipment was worn by all intubating healthcare workers. Rapid sequence induction (RSI) or modified RSI was used with an intubation success rate of 89.1% on the first attempt and 100% overall. Hypoxaemia (Sao₂ <90%) was common during intubation (n=148; 73.3%). Hypotension (arterial pressure <90/60 mm Hg) occurred in 36 (17.8%) patients during and 45 (22.3%) after intubation with cardiac arrest in four (2.0%). Pneumothorax occurred in 12 (5.9%) patients and death within 24 h in 21 (10.4%). Up to 14 days post-procedure, there was no evidence of cross infection in the anaesthesiologists who intubated the COVID-19 patients. Based on clinical information and expert recommendation, we propose detailed planning, strategy, and methods for tracheal intubation in COVID-19 patients.

Keywords: ARDS; COVID-19; airway management; consensus recommendations; critical care; infection prevention and control; pneumonia; respiratory failure; tracheal intubation.

Fig 1

Two layers of personal protective equipment. (a) Inner layer. (b) Outer layer with a face field. (c) Outer layer with a hood without a powered air-purifying respirator (PAPR). (d) Outer layer with a hood PAPR.

Fig 2

Flow chart of recommended tracheal intubation procedure in patients with coronavirus disease 2019 (COVID-19). A suggested strategy based on clinical data for tracheal intubation in 202 patients with COVID-19 from Wuhan, China, and on recommendations from a group of international experts in airway management. Etco₂, end-tidal carbon dioxide; Fio₂, fraction of inspired oxygen; HEPA, high-efficiency particulate air; HFNO, high-flow nasal oxygen; PPE, personal protective equipment.