A coronavirus pandemic with the virus SARS CoV2, causing the disease COVID-19, is rapidly spreading around the world causing significant disruption of health care provision, societal function, and life. Intubation in COVID-19 carries significant risk of infection. We health care workers need to learn how to protect ourselves during COVID-19 intubation because we often don’t think about dangers to ourselves. This article will include links to helpful on-line tools you can use to both learn to protect yourself as well as educate your colleagues. Even if you don’t intubate yourself, the advice covers any scenario where airway contamination, or aerosol generation is likely.

Several months ago I was setting up my OR for the next case. Suddenly my OR RN rushed in and yelled that I was needed stat for an intubation in the emergency room. As I ran into the ED, it was clear that a prolonged and difficult attempt at intubation of an elderly patient with respiratory failure was in progress. My immediate thoughts were:

• “Is the patient being ventilated?”
• “Why does this patient need intubation?”
• “What steps have been tried so far?”
• “What equipment do I have?”

But I also asked: “Do I need to protect myself from this patient with pneumonia?” Although COVID-19 had not yet begun to circulate, I remembered SARS and MERS, and even blogged about MERS at the time.

I quickly donned two pairs of gloves and a regular surgical mask. Intubation was quickly performed. I had not had the opportunity to gown for the intubation. Although the OR was ready to bring my patient in for surgery, I quickly took the time to change scrubs. And of course I washed my hands several times: immediately after intubation before leaving the ED and again when I changed clothes.

Over my career I attended hundreds of emergency intubations. If a patient has MRSA or VRE, Health Care Workers (HCWs) carefully put on cover gowns and gloves and take extreme precautions to prevent its spread. HCWs have often been a lot less compulsive when dealing with respiratory illness — especially in an emergency.

Sobering HCW Infection Statistics

The world has previously dealt with the more limited spread of two prior coronaviruses: Sudden Acute Respiratory Syndrome (SARS CoV) and Middle Eastern Respiratory Syndrome (MERS CoV).

SARS CoV

SARS was a coronavirus which is believed to have crossed over from small wild Chinese carnivores. The SARS epidemic in 2003 gave us a lot of information on the epidemiology of spread of this corona virus, both in patients as well as HCWs. An article in the on-line publication of the University of Minnesota Center For Infectious Disease Research and Policy (CIDRAP) states (1):

“Twenty-two percent of SARS patients in Hong Kong were HCWs. Nosocomial outbreaks of SARS resulted, overall, in 716 secondary and tertiary cases and 52% (410) of these were in HCWs. HCWs with the highest risk of SARS infection were those performing tracheal intubations, working in wards with artificial central ventilation, having face-to-face interactions with SARS patients, wearing single (vs double) gloves, and caring for a ‘super-spreader’ cases.”

Aerosol-generating procedures carried the highest risks of SARS transmission to HCWs, such as:

• endotracheal intubation,
• manipulation of an oxygen mask,
• suction before intubation
• non-invasive manual ventilation

In one retrospective SARS study, not only the intubating doctor, but also the nurses assisting the intubating doctor were at higher risk of infection (2).

MERS CoV

Another corona virus, MERS CoV, appeared in 2012, a crossover virus from camels. According to the CIDRAP article,

19% of the 495 known Middle East respiratory syndrome coronavirus (MERS-CoV) cases, including a number of fatalities, were in healthcare workers (HCWs).

The vast majority of HCW cases—74%—have occurred in the Kingdom of Saudi Arabia, with 24% in the United Arab Emirates. Sixty-three HCW cases—or almost two thirds—were reported last month alone, and more than 60% of the 128 recent MERS patients in Jeddah were infected in a hospital, including 39 HCWs, 6 of whom required intensive care or died.”

The current WHO estimates of severity of COVID-19 illness (as of March 2020) state that 10-15% of patients will develop severe disease and of those 15-20% will be critically ill. Mortality is currently estimated at 3-4%.

SARS CoV2/COVID-19

The new coronavirus might be a crossover from bats. Since it was reported on December 1, 2019 COVID-19 — which is 3 months ago as of this writing — has spread to over 242,191 known cases and killed almost 10,000 patients. Over 80,000 of those infections have been in China. Of those, 1716 were in HCWs, and 6 of those died (as of 2/20).

Italy declared itself a national quarantine zone. In the first two weeks of the Italian epidemic there were 10,149 cases and 631 deaths. Between 10 and 20% of health care workers have caught the virus. Nurse and medical student trainees are being graduated early and retirees are being recalled. The coordinator for intensive care in the crisis unit for the northern Lombardy region told CNN that Lombardy’s health care system was “one step from collapse” despite efforts to free up hospital beds.

“We are now being forced to set up intensive care treatment in corridors,” Antonio Pesenti said. “We’ve emptied entire hospital sections to make space for seriously sick people.” He described seeing “a tsunami of patients,” adding that there could be 18,000 patients in hospital by the end of the month if the virus continues to spread.”

The situation is rapidly changing. For a constantly updated resource tracking the number of diagnosed COVID-19 cases, deaths, and recovered patients in every country worldwide, go to the Johns Hopkins link here.

Protect HCWs During COVID-19 Intubation

Clearly significant risk to health care personnel from respiratory infection exists. Are we doomed if we do a COVID-19 intubation? No! Good attention to self-protection allows both patient care and provider safety.

Hong Kong, which had a 60% HCW infection rate during the SARS outbreak, has so far had no nosocomial infections among healthcare personnel as of this writing. They credit a bundle of protective practices including:

• meticulous use of Personal Protective Equipment (PPE)— especially during airway procedures with likely aerosol generation
• enforced hand-washing compliance
• staff education on infection control
• surgical masks provided for all healthcare workers, patients, and visitors to clinical areas

The full recommendations from the American Society of Anesthesiologists on caring for and intubating COVID-19 infected patients safely can be found here.

A downloadable poster to remind your staff about the following important safety precautions for COVID-19 intubation can be found here.

Wash Your Hands

Wash your hands before donning PPE and after doffing PPE, even if you were wearing gloves. It’s important to wash your hands between all patient encounters for at least 20 seconds. If you can’t wash right away, use alcohol gel. Soap saves.

Upgrade To A N95 Mask

Regular surgical masks are not very efficient at screening out particulates because they almost invariably leak around the edges: 30-50% of particles will leak into the face piece of a well fitting surgical mask. But they are better than no mask at all. The N95 filter masks, when well fitted, allow less than 10% leakage. Now, I dislike the N95 masks as much as the next person because they are uncomfortable, but our health is worth it. Remember to take it off correctly  and safely— more on that in a moment.

Wear Proper PPE

Wear a fluid resistant gown, double glove, and put on a face shield during COVID-19 intubation. Use double gloves because that allows you to discard the contaminated pair after the intubation is complete, but still be protected. Know how to don your PPE. An illustrated, easy to understand instruction sheet from the CDC on donning and doffing Personal Protective Equipment can be found here.

Intubate In A Negative Pressure Room —
If Possible

Intubate in a negative pressure room when possible. Airborne isolation rooms are negative pressure rooms. Air flows in, but not out if the door is opened — preenting spread outside the room. Operating rooms in contrast are positive pressure rooms. They are designed to allow air to flow out, preventing potentially contaminated air from entering. This is the opposite of what you want with a respiratory disease.

Don’t Use High Flow Oxygen 

Intubation is recommended over CPAP and BiPAP because BiPAP can spread aerosols and viral particles. So can high flow oxygen by nasal canula or open mask.

Limit The Number of Personnel

Only essential personnel should be present during the intubation. Not only does this protect personnel, it eliminates a lot of potential chaos.

Avoid Bagging The Patient — If Possible

Manual ventilation creates aerosols and spreads virus. Avoid manual ventilation if possible. This may mean deciding to intubate early.

Use Your Most Experienced Intubator

Now is not the time to teach your resident to intubate or try out a new technique. Intubate in the fastest, most efficient way. Avoid awake intubation if you can because of the risk of aerosol generation.

Dispose of Your PPE Safely

We all know we are supposed to leave the PPE in the room. But I admit that I have seen HCWs disgard their PPEs in all sorts of interesting (and often incorrect) ways. I too have been guilty of sloppy removal if I thought the risks of contamination were low. An illustrated  step by step guide for donning and doffing from the CDC can be found here.

Remembering which surfaces are contaminated and how the PPE is protecting you will help you remember how to safely discard the gear.

• Remove the gown and gloves together without touching the external surfaces. Leave them in the room because taking them out of the room would create a large bulky germ covered bundle.
• Your hands should still be clean. Take off your eye shield by grasping the head strap and without touching the front surface. Discard the shield inside the room.
• Leave the room wearing your mask because if you take the mask off inside the room you will breath in the germs. Take it off outside the room touching only the straps with your clean hands. Don’t touch the mask surface. Discard it in a dedicated receptacle.
• Immediately wash your hands. If you contaminated your hands between any of these steps stop and gel or wash before proceeding. Your hands need to be clean for the next step to be safe.

Do NOT put your used mask in your pocket for later use. Do NOT let your mask dangle about your neck for later use.

Don’t Touch Your Face

We touch our face an average of 23 times an hour, often without even being aware of it. Touching the face, nose and mouth greatly increases the risk of infection if you do have virus on your hands. We must break this habit.

Will This Coronavirus Epidemic Become A Pandemic?

As of this writing, WHO had not yet raised the threat level to pandemic. My school teachers never taught me about the Great 1918 Flu Pandemic. I read about it in a truly sobering history book, The Great Influenza: The Story of the Deadliest Pandemic in History by John M. Barry.

My personal opinion is that the pandemic was so traumatic that people just tried to erase it from their collective consciousness. Most people don’t know that this pandemic killed more people than World War I. Recent estimates put the global death toll between 30 and 60 million people and perhaps as many as 100 million. The majority of them were between 20-40 years of age. The 1918 virus, a so-called swine flu, was so virulent it was known to kill some patients within 24 hours. They simply developed a hemorrhagic pneumonia and drowned in their own fluids during an era when supplemental oxygen was in short supply and artificial ventilation and PEEP did not yet exist.

Why Did 1918 Flu Spread So Far So Fast?

The fact that it spread so far, and so fast, came from the fact that a new, highly contagious and lethal virus, to which few people had immunity, arrived on the scene at the exactly the wrong time when the world was in chaos.

• World War I was in progress. There was fighting in Europe, Africa and Asia. For the first time in the world’s history millions of people were on the move at the same time, from troop movements to refugees. People were living in close quarters. And the virus moved with them.
• Because of the war, there was tacit press censorship prohibiting anything that would hurt morale from being published. People were picking their own facts to support their own ideologies. The start of the pandemic thus went unnoticed by many until too late.
• Shear numbers of cases overwhelmed the medical system. In addition, lack of adequate medical personnel in remote or war torn areas further disrupted care and hampered containment

How Does Today Compare To 1918?

The world is pretty chaotic. Our current world is filled with war torn areas. According to the UN Refugee Agency, there are now more than 50 million global refugees, more than at any time since World War II. AS during the war, some leaders are choosing to hide certain truths to minimize hits to morale or economics. People are once again tending to pick the facts they like and discard the facts that don’t fit their beliefs. And any one of us can be anywhere in the world within 24 hours just by getting on an airplane. Twenty four hours is a lot shorter than just about any incubation period.

And once again the world does not have any immunity to the circulating virus SARS CoV2 and its disease COVID-19.

Whether COVID-19 will be a pandemic or not, we health care workers need to be serious about protecting ourselves when we are managing any patient with respiratory failure. You never know when the next patient you intubate could infect YOU.

Additional Reading

(1) Tran K, Cimon K, Severn M, et al. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PloS One 2012;7(4):e35797.

(2) Fowler, et. al. Transmission of Severe Acute Respiratory Syndrome during Intubation and Mechanical Ventilation. American journal of respiratory and critical care medicine. Vol 169. 2004

May The Force Be With You!

Christine E Whitten MD, author
Anyone Can Intubate: A Step By Step Guide
and
Pediatric Airway Management: a Step by Step Guide