Emergency Airway Management in Patients with COVID-19: A Prospective International Multicenter Cohort Study

Abstract

Background: Tracheal intubation for patients with COVID-19 is required for invasive mechanical ventilation. The authors sought to describe practice for emergency intubation, estimate success rates and complications, and determine variation in practice and outcomes between high-income and low- and middle-income countries. The authors hypothesized that successful emergency airway management in patients with COVID-19 is associated with geographical and procedural factors.

Methods: The authors performed a prospective observational cohort study between March 23, 2020, and October 24, 2020, which included 4,476 episodes of emergency tracheal intubation performed by 1,722 clinicians from 607 institutions across 32 countries in patients with suspected or confirmed COVID-19 requiring mechanical ventilation. The authors investigated associations between intubation and operator characteristics, and the primary outcome of first-attempt success.

Results: Successful first-attempt tracheal intubation was achieved in 4,017/4,476 (89.7%) episodes, while 23 of 4,476 (0.5%) episodes required four or more attempts. Ten emergency surgical airways were reported-an approximate incidence of 1 in 450 (10 of 4,476). Failed intubation (defined as emergency surgical airway, four or more attempts, or a supraglottic airway as the final device) occurred in approximately 1 of 120 episodes (36 of 4,476). Successful first attempt was more likely during rapid sequence induction versus non-rapid sequence induction (adjusted odds ratio, 1.89 [95% CI, 1.49 to 2.39]; P < 0.001), when operators used powered air-purifying respirators versus nonpowered respirators (adjusted odds ratio, 1.60 [95% CI, 1.16 to 2.20]; P = 0.006), and when performed by operators with more COVID-19 intubations recorded (adjusted odds ratio, 1.03 for each additional previous intubation [95% CI, 1.01 to 1.06]; P = 0.015). Intubations performed in low- or middle-income countries were less likely to be successful at first attempt than in high-income countries (adjusted odds ratio, 0.57 [95% CI, 0.41 to 0.79]; P = 0.001).

Conclusions: The authors report rates of failed tracheal intubation and emergency surgical airway in patients with COVID-19 requiring emergency airway management, and identified factors associated with increased success. Risks of tracheal intubation failure and success should be considered when managing COVID-19.

Fig. 1.

Flowchart of cases included and excluded from the analysis. ICU, intensive care unit.

Fig. 2.

Countries with participants submitting data to the study, colored by Organisation for Economic Co-operation and Development income level.

Fig. 3.

Personal protective equipment used by operators during tracheal intubation episodes, stratified by Organisation for Economic Co-operation and Development income status of the countries where the episodes were reported from.

Fig. 4.

Plot of the association between the number of previous COVID-19 tracheal intubations before current intubation episode and the likelihood of successfully intubating at first attempt (predicted success computed from the mixed-effects logistic regression model). In this plot, the other model covariates are set to the mean (for numeric variables) or set to their reference level (for categorical variables). The black line indicates the prediction estimate for a given number of previous COVID-19 tracheal intubations adjusted for other covariates, and the gray area indicates the 95% CI of the prediction estimate.