Awake tracheal intubation in a suspected COVID‐19 patient with critical airway obstruction

Abstract

We report the airway management of a patient with suspected COVID-19 with impending airway obstruction requiring urgent surgical tracheostomy. To our knowledge, this is the first reported case of an awake tracheal intubation in a suspected COVID-19-positive patient. Various modifications were put in place during the awake tracheal intubation and surgical tracheostomy procedures to minimise aerosol generation from the patient, such as avoiding high-flow nasal oxygen, establishing conscious sedation with remifentanil before commencing airway topicalisation and avoiding transtracheal local anaesthetic infiltration. A multidisciplinary team discussion before performing the case highlighted aspects of both the airway management and the surgical procedure where particular care and modifications are required. There is a lack of national and international guidance for awake tracheal intubation and tracheostomy in COVID-19 cases. This report nevertheless addresses the key procedural modifications required.

Unconventional multidisciplinary team strategy for tracheostomy in COVID‐19

“…There has been a very high requirement for tracheal intubation and mechanical ventilation, and subsequently for tracheostomy. We established mobile emergency rapid intubation teams (MERIT) early in the pandemic response, which follow specific protocols for personal protective equipment (PPE) and minimising aerosol generation and thus operator risk of infection [2]. Mobile emergency rapid intubation teams, consisting of two consultant anaesthetists and two assistants, are responsible for all COVID‐19 tracheal intubations in the hospital [3].…”

A multidisciplinary approach for managing the infraglottic difficult airway in the setting of the Coronavirus pandemic

“…An additional specific consideration with infraglottic airway obstruction is the risk of aerosol generation from air turbulence due to normal tidal breathing through a tight stricture compared with the use of nasal high flow. We do and have on this basis therefore use nasal high-flow in the settings of awake tracheal intubation and as a temporary holding intervention in the specific setting of acute airway compromise due to an infraglottic obstruction just prior to definitive management 14…”

Review of Anaesthesia and Analgesia in Patients with COVID-19 in Brazil

“…Because it is an ultra-fast opioid with a short duration of action, it is associated with the rapid development of tolerance. In the case report by Ahmad et al, 4 ng/ml remifentanil and 0.5 μg/ml propofol were used for conscious sedation, and 6 ng/ml remifentanil with 3 μg/mL propofol with 60 mg of rocuronium for anaesthetic induction [23]. In order to reduce the chances of coughing as much as possible during the intubation process, a higher than the recommended dose of remifentanil was used, and the procedure started after the drug reached its maximum effect.…”