Expert Recommendations for Tracheal Intubation in Critically Ill Patients with Noval Coronavirus Disease 2019

Coronavirus Disease 2019(COVID-19),caused by a novel coronavirus(SARS-Co V-2),is a highly contagious disease.It firstly appeared in Wuhan,Hubei province of China in December 2019.During the next two months,it moved rapidly throughout China.Most of the infected patients have mild symptoms including fever,fatigue and cough,but in severe cases,patients can progress rapidly and develop into acute respiratory distress syndrome,septic shock,metabolic acidosis and coagulopathy.The new coronavirus was reported to spread via droplets,contact and natural aerosols from human to human.Therefore,aerosol-producing procedures such as endotracheal intubation may put the anesthesiologists at high risk of nosocomial infections.In fact,SARSCo V-2 infection of anesthesiologists after endotracheal intubation for confirmed COVID-19 patients have been reported in hospitals in Wuhan.The expert panel of airway management in Chinese Society of Anaesthesiology has deliberated and drafted this recommendation,by which we hope to guide the performance of endotracheal intubation by frontline anesthesiologists and critical care physicians.During the airway management,enhanced droplet/airborne personal protective equitment(PPE)should be applied to the health care providers.A good airway assessment before airway intervention is of vital importance.For patients with normal airway,awake intubation should be avoided,and modified rapid sequence induction is strongly recommended.Sufficient muscle relaxant should be assured before intubation.For patients with difficult airway,good preparation of airway devices and detailed intubation plans should be made.

Reply to Letter to the Editor

WE read with interest the commentary by Vahid Damanpak Moghadam and colleagues.As a matter of fact,Coronavirus Disease 2019(COVID-19)has been pandemic globally in a very fast speed and raised great concern all over the world.To provide guidance for anesthesiologists and critical care physicians on performance of endotracheal intubation for COVID-19 patients.

Expert consensus on difficult airway assessment

Background:Identifying a potentially difficult airway is crucial both in anaesthesia in the operating room(OR)and non-operation room sites.There are no guidelines or expert consensus focused on the assessment of the difficult airway before,so this expert consensus is developed to provide guidance for airway assessment,making this process more standardized and accurate to reduce airway-related complications and improve safety.Methods:Seven members from the Airway Management Group of the Chinese Society of Anaesthesiology(CSA)met to discuss the first draft and then this was sent to 15 international experts for review,comment,and approval.The Grading of Recommendations,Assessment,Development and Evaluation(GRADE)is used to determine the level of evidence and grade the strength of recommendations.The recommendations were revised through a three-round Delphi survey from experts.Results:This expert consensus provides a comprehensive approach to airway assessment based on the medical history,physical examination,comprehensive scores,imaging,and new developments including transnasal endoscopy,virtual laryngoscopy,and 3D printing.In addition,this consensus also reviews some new technologies currently under development such as prediction from facial images and voice information with the aim of proposing new research directions for the assessment of difficult airway.Conclusions:This consensus applies to anesthesiologists,critical care,and emergency physicians refining the preoperative airway assessment and preparing an appropriate intubation strategy for patients with a potentially difficult airway.