intubateCOVID: understanding practice and risks of tracheal intubation in COVID-19

Anaesthetists and intensivists everywhere are finding the world which they normally navigate is changing at breakneck speed because of something invisible to the naked eye. The coronavirus disease-2019 (COVID-19) pandemic has meant the cancellation of routine elective surgery in many hospitals, and the redeployment of anaesthetists into intensive care units (ICU) to supplement their intensivist colleagues in caring for critically ill COVID-19 patients. Respiratory failure is a common complication of COVID-19 and many patients with the disease eventually require tracheal intubation for invasive mechanical ventilation. Although it is a procedure that many of us in the Royal College of Anaesthetists and Faculty of Intensive Care Medicine would be well-practiced in, there are some concerns when it is performed in COVID-19 patients.

Tracheal intubation is thought to be an aerosol generating procedure (AGP) which has the potential to turn airway secretions into fine particles, possibly spreading great distances, and thus is considered a high-risk for transmitting the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), the virus that causes COVID-19, to staff present during the procedure. Therefore, wearing personal protective equipment (PPE), including filtering facepieces and eye-protection has been advised¹.

However, the risks to intubators and other assisting staff of contracting COVID-19 are unclear, and the limited literature suggesting tracheal intubation carries a high-risk of viral transmission has largely been based on the earlier SARS epidemic which occurred almost two decades ago². There is therefore a need to accurately estimate the true risk of COVID-19 transmission in airway managers and others present during tracheal intubation, so that those at the frontlines understand the hazards they face when caring for patients with the disease.

To that end, my colleagues and I at Guy’s and St Thomas’ NHS Foundation Trust, in conjunction with the Difficult Airway Society (DAS), have rapidly developed and deployed the intubateCOVID project, an online registry to collect data about COVID-19 tracheal intubations.

In the UK, this registry has received endorsement by the Royal College of Anaesthetists, Association of Anaesthetists, Intensive Care Society, Royal College of Surgeons and the Royal College of Emergency Medicine. It has also at the time of writing received support from organisations in 12 other countries worldwide, comprising Australia, Canada, Czech Republic, Germany, India, Ireland, New Zealand, Poland, South Africa, Sweden, The Netherlands and the US, making this a truly international project. Interest is growing and we are onboarding new countries every few days.

The project launched in late March and in less than a month, we have received data from over 1,500 anaesthetists, intensivists, nurses, anaesthetic assistants and other allied health professionals in over 400 hospitals, and have recorded close to 4,000 tracheal intubation events. We are recording details of the tracheal intubations, including the types of PPE worn by staff, location of the intubation and other information that might inform health professionals worldwide about potential variations in practice which might exist when performing this high-risk AGP. Data entry is quick and can be done on users’ smartphones in about a minute, therefore making the process painless and unobtrusive.

More importantly, we are collecting vital follow-up outcome data about intubators and their assistants. We are logging incidences where they contract COVID-19 symptoms or receive laboratory-confirmed COVID-19 diagnoses or get admitted to hospital in the period after their AGP exposures. Users of the registry receive an automated weekly reminder email that nudges them to log in to the system to record details of any COVID-19 symptoms they might be experiencing.

Rather than relying on a single big publication of data at the end of the pandemic to disseminate change, we hope to feed data back dynamically to users through innovative use of dashboards, and social media. We hope that the data crowdsourced from health professionals internationally can be used in near real-time to improve patient care.

It is our hope that readers and colleagues in the UK and the international anaesthetic, critical care and emergency medical community will sign up and contribute to the registry, and help to provide the much-needed data that will help inform our practice, making it safer for everyone involved.

Danny Wong

References:

1. Cook, T.M., El‐Boghdadly, K., McGuire, B., McNarry, A.F., Patel, A. and Higgs, A. (2020), Consensus guidelines for managing the airway in patients with COVID‐19. Anaesthesia. doi:10.1111/anae.15054
2. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS ONE 2012; 7: e35797