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intubateCOVID – How to Get First-Pass Success in COVID Patients

September 29, 2021

Written by Clay Smith

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When intubating COVID-19 confirmed or suspected patients, greater experience, use of RSI, use of a PAPR, and intubation in a high vs low-income country were all associated with higher first pass success.

Why does this matter?
As we all know, we are often called on to intubate COVID positive or COVID suspected patients. First pass success (FPS) is always important, but it’s more crucial in COVID patients, so we can have the viral filter in line to reduce COVID aerosols. What can we do to optimize FPS in these patients?

Let’s do this aerosol generating procedure right

Design: This was a multicenter, multinational prospective cohort from May 2020 to October 2020 from high and low-income countries to determine what factors were associated with FPS in patients with known or suspected COVID-19 who needed an emergency airway.

Results: They included 4,476 emergency tracheal intubations. These were performed by 1,722 clinicians, 607 institutions, 32 countries; 65% of cases were from the US and UK. Most intubations were performed by anesthesia, followed distantly by critical care. FPS occurred in 89.7% of cases and was associated with RSI (vs not RSI), powered air-purifying respirator (PAPR) use, prior experience intubating COVID-19 patients, and the procedure being done in a high-income country. On that last point, patients were almost half as likely to have FPS in a low vs high-income country, aOR0.57 (95%CI 0.41-0.79).

Implications: Get the best person in the room, use RSI, put on a PAPR, and hope you practice in a place with resources.

Limitations: It is not known what contributed to lower FPS in lower income countries. It may have been due to much lower videolaryngoscope use, although there was no statistical difference in this cohort between VL and DL. It also may have been that patients had more delayed and severe presentations in lower income countries.

Emergency Airway Management in Patients with COVID-19: A Prospective International Multicenter Cohort Study. Anesthesiology. 2021 Aug 1;135(2):292-303. doi: 10.1097/ALN.0000000000003791.

What are your thoughts?