key: cord-1048320-6pxu2vgy authors: Crawley, S. M.; McGuire, B. title: New dimensions in airway management: risks for healthcare staff date: 2020-08-06 journal: Anaesthesia DOI: 10.1111/anae.15223 sha: 96eaf8be7f99a14922d9a50acf875419fc9e0b52 doc_id: 1048320 cord_uid: 6pxu2vgy nan In April 2020, the World Health Organization (WHO) confirmed the novel coronavirus disease (COVID-19) as a pandemic, with horrific death tolls on a global scale, including many brave healthcare workers. As experiences from our Italian colleagues started to filter through, many of us delivered staff training for COVID-19 adaptations to airway management and it was soon clear that the mood was different. The willingness to learn was ever present, but a new, palpable nervousness resided throughout the groups. Many colleagues were scared, ourselves included; like watching a tsunami from the shore, waiting for it to hit. The anxiety stemmed largely from the thought that an overwhelming number of patients may require intubation, but also unease based on personal risk, as frontline healthcare workers and, in particular, airway managers. Tracheal intubation and facemask ventilation rank highly on the WHO list of aerosol-generating procedures with odds ratios of infection at 6.6 and 2.8, respectively [1] . In carrying out our role, we and our team members would be right up close and personal to this frightening disease. In this issue of Anaesthesia, El-Boghdadly et al. report the first prospective data collection on the issue of infection risk to healthcare workers managing the airway in patients with confirmed or suspected COVID-19 infection [2] . This was a collaborative international effort, involving 503 hospitals in 17 countries and all contributors to its rapid set-up and completion should be commended. The study team conducted a multicentre prospective data collection seeking fixed answer data, through a purpose- Although an international study, the majority of submitted cases originated from the UK (48.6%) and the USA (21.9%) and so examination of the data from El-Boghdadly et al. requires an awareness of clinical practice in these countries. Within the intubation procedural characteristics detected by El-Boghdadly et al, it appears that much of that collaborative national guidance filtered down to be actioned on the ground. Most intubations were performed out with the operating theatre (83%), in environments associated with worse outcomes [3] . This in itself may not be worthy of comment other than the fact that the reported intubation success rate was 98% for two attempts, an impressive figure for this patient cohort. In recognition of this high-risk scenario, intubation teams largely consisted of senior level staff (70%) and team size was kept to a minimum with 76% having four or fewer team members, maximising first-pass success, and reducing team exposure. Tracheal intubation in ICU is a high-risk procedure for patients, having been described as a physiologically difficult airway [4] . Hypoxaemia before commencing airway management is unsurprisingly associated with increased complications, even if the intubation is successful on the first attempt [5] . Peri-oxygenation techniques are paramount to patient safety and are employed to extend apnoea times, which can improve clinician performance as well as maintaining adequate haemoglobin saturation. Such Some supported its use but only with limited flow rates, in an effort to reduce gas consumption and aerosolisation risk. Evidence of staff risk is sparse but studies examining droplet dispersal at varying flow rates, up to 60 l.min À1 showed limited dispersion distances, although this increased significantly with coughing [8, 9] . Many advantages of highflow nasal oxygen are flow-relatedwork of breathing and positive airway pressure generation are improved at higher ratesthus, effort to cap flow rates could reduce therapeutic efficacy for little safety gain. Peri-intubation high-flow nasal oxygen use in COVID-19 physiologically difficult airways was advised against as it was felt that the risk to intubators in close proximity outweighed patient benefit [6] . This consensus probably accounts for the relatively low incidence of use (6.4%) in critical care intubations from the series by El-Boghdadly et al. Before the pandemic, modern practice had been moving away from the classical construct of the rapid sequence intubation where manual ventilation was avoided. Gentle ventilation following induction reduces desaturation, maintains a degree of recruitment and its use post-induction was promoted in critically ill and obstetric patients at risk of desaturation [10, 11] . In COVID-19, modern practice was again adapted, and manual ventilation was reserved for rescue ventilation, being a reactive action to desaturation. [6, 10] . Videolaryngoscopy is recognised to improve team dynamic, improve view and delivers a higher first-pass success than direct laryngoscopy, all of which may shorten the time to establishing a secure airway as a result of additional attempts or failure [12] . Another aspect of its promotion is the increase in patient-operator distance, with the guise of moving the operator out of droplet dispersal range [13] . In this study, videolaryngoscopy was used in 76 % of intubations, contributing to an overall 90 % first-pass success. The first-pass success rate of intubation in the critically ill can be less 80%, with up to 20% of intubations taking more than three attempts [14] . Though intubator seniority will undoubtedly have been a contributory factor, the apparent success of videolaryngoscopy in these challenging patients enhances the "make your first attempt your best attempt" concept and may trigger a reinvigorated push for universal videolaryngoscopy, a goal that many strive for but only a few have achieved [15] . Another important issue is airway training. The recent impact of the pandemic on trainee exposure to airway management has been stark. As we move forward, the reduction in elective surgery, particularly high-turnover lists of minor cases, and the practice of minimising staff present during airway management will continue. With increasing pressure to ensure our new trainees get adequately trained, there is an argument for targeting competent skill in one intubation technique rather than partial skill in two. Given the evidence that Macintosh videolaryngoscopy is an effective way to teach direct laryngoscopy, this may be the way intubation training should go [16] . The risks to airway managers can be mitigated by two main approaches, namely adequate provision of airborne protective personal protective equipment (PPE); and the adoption the aforementioned approaches and techniques considered to minimise aerosolisation or transmission. More novel innovations, such as the aerosol box, trended, but never gained official endorsements and eventually were shown to be unhelpful in many respects [17, 18] . The initial headline data from Wuhan on intubation of COVID-19 patients was likely reassuring to most after publication of a zero-operator infection rate following 202 intubations undergoing modified rapid-sequence intubation, including bag-mask ventilation before laryngoscopy [19] . However, on closer examination, the dual layer personal protective equipment system used by intubators in this study is likely to have been more robust than most others have access to given the new worldwide demand. Also, the 14-day isolation that followed periods of work, removing potential pre-symptomatic infected staff from the workforce, will not be feasible in many healthcare systems. Furthermore, COVID-19 testing and optional chest CT was required before returning to work. Hence, comparison between the two datasets is difficult. Seventy-seven percent of healthcare workers in the UK are women; however, there were not more female participants in this series [20] . 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