Airway management in a prehospital setting during the SARS-CoV-2 pandemic

The SARS-CoV-2 pandemic has significantly changed the day-to-day work of emergency medical services. Due to clinical challenges in the treatment of SARS-CoV-2 in emergency and intensive care units, infection control of all healthcare professionals involved should become the focus.

PERSONAL PROTECTIVE EQUIPMENT

The authors recommend wearing minimum personnel protection equipment (PPE; at least FFP3 mask, eye protection, e.g. visor or goggles, hood, liquid-tight protective gown, disposable gloves) in the current situation for the process of airway management in confirmed and suspect patients. Clear plastic sheeting or intubation domes for intubation of patients with COVID-19 have been additionally implemented in many places in the clinical setting [1–4]. Simulation data in the clinical setting show an extension of the intubation time and reduce the first pass rate [5], so that an implementation in the preclinical setting seems difficult and only makes sense with sufficient training.

AIRWAY MANAGEMENT

In emergency medical services, airway management is crucial. Prehospital emergency medicine also provides different experiences of the staff in airway management, and in addition the rescue systems are equipped very differently.
Endotracheal intubation using direct laryngoscopy without adequate protection represents a high risk of SARS-CoV-2 infection. Invasive ventilation and bronchoscopy are procedures with high exposure to aerosol generation and therefore are associated with an increased risk of infection [6]. Basically, two mechanisms of distribution can be differentiated: droplets (> 5–10 microns diameter) or airborne particles (< 5 microns diameter). The droplets reach an area of approximately 1-2 metres around the patient. Airborne particles, however, can float in the air for a longer period of time before they descend [7].
Securing the airway in a prehospital setting is usually an emergency procedure, and preparation for intubation is not feasible. Therefore, the authors recommend the development of an adapted local algorithm for emergency tracheal intubation in possible COVID-19 patients. The special procedure should be trained regularly within the team with a focus on available equipment.
The algorithm should include following points [8]:
• use of adequate PPE,
• preoxygenation using a rebreathing circuit,
• rapid sequence induction (RSI),
• avoidance of bag-ventilation when possible or...


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