For patients with suspected or confirmed COVID-19 who require intubation, a number of guidelines and reviews have recommended tracheal intubation is conducted with a video laryngoscope in preference to a direct laryngoscope.1,2,3
A video laryngoscope allows the clinician to view the anatomical structures on a screen or monitor, positioning them further away from the face of the patient than a direct laryngoscope, thereby potentially reducing the risk of exposure to patient respiratory aerosols and transmission of infection.4,5
Video laryngoscopy may also offer additional benefits to the clinician when intubating patients with COVID-19, where the objective is to achieve first-pass success and multiple attempts at intubation are likely to increase risk to both healthcare personnel and patients.
A set of guidelines for managing the airway in patients with COVID-19 from the UK Difficult Airway Society, the Association of Anaesthetists, the Intensive Care Society, Royal College of Anaesthetists and the Faculty of Intensive Care Medicine, has been published in the journal Anaesthesia.
In the section regarding the fundamentals of airway management for a patient with suspected or confirmed COVID-19, it is recommended to, ‘Use techniques that are known to work reliably across a range of patients, including when difficulty is encountered.’ The list includes video laryngoscopy for tracheal intubation, and a 2nd generation supraglottic airway for airway rescue. For emergency tracheal intubation, the authors confirm that, ‘laryngoscopy should be undertaken with the device most likely to achieve prompt first-pass tracheal intubation in all circumstances in that operator’s hands – in most fully trained airway managers this is likely to be a video laryngoscope.’1
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In regard to resuscitation, The European Resuscitation Council COVID-19 Guidelines for Advanced Life Support in adults, confirm that,
'Experienced airway staff should insert a supraglottic airway or intubate the trachea early so that the period of bag-mask ventilation is minimised. Consider video-laryngoscopy for tracheal intubation by providers familiar with its use – this will enable the intubator to remain further from the patient’s mouth.’ 6
While none of the above papers recommend a specific video laryngoscope, it has been suggested in some articles there may be a benefit to devices with a separate screen. In one paper, this is recommended on the basis that it enables the user to stay further away from the airway.1
However, whether this is correct has yet to be established, since the operator is still required to hold the video laryngoscope in place, limiting the distance they can be from the patient’s head during the procedure. A separate screen may also have disadvantages, particularly if it is not optimally positioned and may draw the attention of the operator away from the patient’s head if it is not located centrally. A separate screen also introduces additional components to the intubation room and, unless single use, will be another piece of equipment requiring some form of cleaning, disinfection and reprocessing prior to reuse.1
References
1. Cook T.M, El-Boghdadly K, McGuire B, McNarry A.F, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists, the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia 2020; 75: 785-99
2. Yao W, Wang T, Jiang B, Gao F, Wang L, Zheng H, Xiao W, Yao S, Mei W, Chen X, Luo A, Sun L, Cook T, Behringer A, Huitink J.M, Wong D.T, Lane-Fall M, McNarry A.F, McGuire B, Higgs A, Shah A, Patel A, Zuo M, Ma W, Xue Z, Zhang L.M, Li W, Wang Y, Hagberg C, O'Sullivan E.P, Fleisher L.A, Wei H. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations. British Journal of Anaesthesia 2020; 125: 28-37
3. The World Federation of Societies of Anaesthesiologists (WFSA). Coronavirus - guidance for anaesthesia and perioperative providers [Internet]. World Federation of Societies of Anaesthesiologists. World Federation of Societies of Anaesthesiologists; 2020 [cited 2021 Jan 07]. Available from: https://wfsahq.org/wp-content/uploads/Guidance_on_COVID-19_and_anaesthesia.pdf
4. Wax R.S, Christian M.D. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Canadian Journal of Anaesthesia 2020; 67: 568-76
5. Zeidan A, Bamadhaj M, Al-Faraidy M, Ali M. Videolaryngoscopy Intubation in Patients with COVID-19: How to Minimize Risk of Aerosolization?. Anesthesiology 2020; 133:
481-3
6. Soar J, Lott C, Bottiger B.W, Carli P, Couper K, Deakin C.D, Djarv T, Olasveengen T, Paal P, Pellis T, Perkins G.D, Sandroni C, Nolan J.P. Advanced Life Support in Adults. In: European Resuscitation Council COVID-19 Guidelines: European Resuscitation Council; 2020