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      Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID‐19 adult patient group

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          Abstract

          Introduction

          This statement was planned on 11 March 2020 to provide clinical guidance and aid staff preparation for the coronavirus disease 2019 ( COVID‐19) pandemic in Australia and New Zealand. It has been widely endorsed by relevant specialty colleges and societies.

          Main recommendations

          • Generic guidelines exist for the intubation of different patient groups, as do resources to facilitate airway rescue and transition to the “can't intubate, can't oxygenate” scenario. They should be followed where they do not contradict our specific recommendations for the COVID‐19 patient group.

          • Consideration should be given to using a checklist that has been specifically modified for the COVID‐19 patient group.

          • Early intubation should be considered to prevent the additional risk to staff of emergency intubation and to avoid prolonged use of high flow nasal oxygen or non‐invasive ventilation.

          • Significant institutional preparation is required to optimise staff and patient safety in preparing for the airway management of the COVID‐19 patient group.

          • The principles for airway management should be the same for all patients with COVID‐19 (asymptomatic, mild or critically unwell).

          • Safe, simple, familiar, reliable and robust practices should be adopted for all episodes of airway management for patients with COVID‐19.

          Changes in management as a result of this statement

          Airway clinicians in Australia and New Zealand should now already be involved in regular intensive training for the airway management of the COVID‐19 patient group. This training should focus on the principles of early intervention, meticulous planning, vigilant infection control, efficient processes, clear communication and standardised practice.

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          Most cited references 7

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          Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

          Summary Background A recent cluster of pneumonia cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). We report the epidemiological, clinical, laboratory, and radiological characteristics and treatment and clinical outcomes of these patients. Methods All patients with suspected 2019-nCoV were admitted to a designated hospital in Wuhan. We prospectively collected and analysed data on patients with laboratory-confirmed 2019-nCoV infection by real-time RT-PCR and next-generation sequencing. Data were obtained with standardised data collection forms shared by WHO and the International Severe Acute Respiratory and Emerging Infection Consortium from electronic medical records. Researchers also directly communicated with patients or their families to ascertain epidemiological and symptom data. Outcomes were also compared between patients who had been admitted to the intensive care unit (ICU) and those who had not. Findings By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (30 [73%] of 41); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]). Median age was 49·0 years (IQR 41·0–58·0). 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0–13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα. Interpretation The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies. Funding Ministry of Science and Technology, Chinese Academy of Medical Sciences, National Natural Science Foundation of China, and Beijing Municipal Science and Technology Commission.
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            Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.

            This project was devised to estimate the incidence of major complications of airway management during anaesthesia in the UK and to study these events. Reports of major airway management complications during anaesthesia (death, brain damage, emergency surgical airway, unanticipated intensive care unit admission) were collected from all National Health Service hospitals for 1 yr. An expert panel assessed inclusion criteria, outcome, and airway management. A matched concurrent census estimated a denominator of 2.9 million general anaesthetics annually. Of 184 reports meeting inclusion criteria, 133 related to general anaesthesia: 46 events per million general anaesthetics [95% confidence interval (CI) 38-54] or one per 22,000 (95% CI 1 per 26-18,000). Anaesthesia events led to 16 deaths and three episodes of persistent brain damage: a mortality rate of 5.6 per million general anaesthetics (95% CI 2.8-8.3): one per 180,000 (95% CI 1 per 352-120,000). These estimates assume that all such cases were captured. Rates of death and brain damage for different airway devices (facemask, supraglottic airway, tracheal tube) varied little. Airway management was considered good in 19% of assessable anaesthesia cases. Elements of care were judged poor in three-quarters: in only three deaths was airway management considered exclusively good. Although these data suggest the incidence of death and brain damage from airway management during general anaesthesia is low, statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported. It therefore provides an indication of the lower limit for incidence of such complications. The review of airway management indicates that in a majority of cases, there is 'room for improvement'.
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              Difficult Airway Society Guidelines for the management of tracheal extubation.

              Tracheal extubation is a high-risk phase of anaesthesia. The majority of problems that occur during extubation and emergence are of a minor nature, but a small and significant number may result in injury or death. The need for a strategy incorporating extubation is mentioned in several international airway management guidelines, but the subject is not discussed in detail, and the emphasis has been on extubation of the patient with a difficult airway. The Difficult Airway Society has developed guidelines for the safe management of tracheal extubation in adult peri-operative practice. The guidelines discuss the problems arising during extubation and recovery and promote a strategic, stepwise approach to extubation. They emphasise the importance of planning and preparation, and include practical techniques for use in clinical practice and recommendations for post-extubation care. Anaesthesia © 2012 The Association of Anaesthetists of Great Britain and Ireland.
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                Author and article information

                Contributors
                dbrewster@cabrini.com.au
                Journal
                Med J Aust
                Med. J. Aust
                10.5694/(ISSN)1326-5377
                MJA2
                The Medical Journal of Australia
                John Wiley and Sons Inc. (Hoboken )
                0025-729X
                1326-5377
                01 May 2020
                June 2020
                : 212
                : 10 ( doiID: 10.5694/mja2.v212.10 )
                : 472-481
                Affiliations
                [ 1 ] Monash University Melbourne VIC
                [ 2 ] Cabrini Hospital Melbourne VIC
                [ 3 ] Safe Airway Society Melbourne VIC
                [ 4 ] Alfred Hospital Melbourne VIC
                [ 5 ] Royal North Shore Hospital Sydney NSW
                Author notes
                Article
                MJA250598
                10.5694/mja2.50598
                7267410
                32356900
                © 2020 AMPCo Pty Ltd

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                Page count
                Figures: 0, Tables: 0, Pages: 10, Words: 7988
                Product
                Funding
                Funded by: Royal College of Anaesthetists COVID‐19
                Categories
                Infectious Diseases
                Anesthesia, Analgesia and Pain
                Emergency Medicine
                Consensus Statements
                Research and Reviews
                Consensus Statements
                Custom metadata
                2.0
                June 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.3 mode:remove_FC converted:03.06.2020

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