Intubation/Extubation: a High-Risk Aerosol Generating COVID Procedure?

I remember like it was yesterday the first COVID patient who I intubated. I was scared. Heck, I still have a healthy respect for the procedure because these patients don’t do well on the vent. In addition, they tend to tank their O2 sats as soon as the RSI drugs kick in. Everything needs to go perfectly. My team and I have a game plan with contingencies before we walk into the room to perform the intubation. Everything is set up to the best of our abilities. To be honest I treat every single airway with the utmost respect. If something goes wrong the patient could die. To add to these concerns, we now have to worry about aerosolizing the COVID virus. This can potentially get myself or my team sick. But how much do we need to worry about intubation or extubation of patients with COVID?

After several months being in the COVID suck, I cannot comment on how many COVID patients I have intubated. But I can say I feel plenty safe in my PPE (I do have my own respirator for airways, btw). Now there’s data that states that perhaps intubation is not as risky as we all thought it was and that’s definitely a good thing. Given the findings of this paper, I am not going to change a single thing in my approach to intubation.

What’s the risk of intubation or extubation in COVID?

Brown, et al. was concerned about the “lack of quantitative evidence on the number and size of airborne particles produced during aerosol-generating procedures”. They sought out ways to investigate this. To sort this out they “conducted real-time, high-resolution environmental monitoring in ultraclean ventilation operating theatres during tracheal intubation and extubation sequences”. Bravo.

The article is completely free and you can read it for yourself and not trust me. After all, this is about your health and that of your teammates. You don’t want your data from some dude on social media who pretends to be a doctor. Besides, they did a bunch of fancy pants stuff that I can’t admit to fully understanding. All in all, though, they found that neither intubation nor extubation are as bad as expected with regards to generating aerosols. In fact, they do not “support the designation of elective tracheal intubation as an aerosol-generating procedure”.

Extubation was a little worse as it generates more detectable aerosol than intubation but still falls below the current criterion for designation as a high risk aerosol-generating procedure. I guess we don’t have to undo the restraints, take down the cuff, and let patients extubate themselves after all like some suggested at the beginning of the pandemic. Hope this is helpful to know about intubation and extubation of patients with COVID.

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Brown J, Gregson FKA, Shrimpton A, Cook TM, Bzdek BR, Reid JP, Pickering AE. A quantitative evaluation of aerosol generation during tracheal intubation and extubation. Anaesthesia. 2020 Oct 6. doi: 10.1111/anae.15292. Epub ahead of print. PMID: 33022093.
Link to Article

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