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Letter to the Editor| Volume 153, P35-36, August 2020

Ventilation and airway management during Cardiopulmonary Resuscitation in COVID-19 era

Published:June 03, 2020DOI:https://doi.org/10.1016/j.resuscitation.2020.05.043
Ventilation and airway management during Cardiopulmonary Resuscitation in COVID-19 era
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      Dear Editor
      We compliment Scapigliati and colleagues
      • Scapigliati A.
      • Gullì A.
      • Semeraro F.
      • et al.
      How to ventilate during CPR in time of Covid-19?.
      Resuscitation. 2020; (pii: S0300-9572(20)30174-X)https://doi.org/10.1016/j.resuscitation.2020.04.036
      for the aerosol-limiting solution with a supraglottic airway (SAD) during advanced life support for cardiac arrest, but we have concerns.
      Cardiopulmonary Resuscitation (CPR) in COVID-19 pandemic posed unprecedented challenges for healthcare providers (HCP): safety before patients’ needs.

      ERC COVID-19 Guidelines: (Accessed 10 May 2020, at https://www.erc.edu/sites/5714e77d5e615861f00f7d18/content_entry5ea884fa4c84867335e4d1ff/5ea886c54c84867421e4d1fc/files/ERC_covid19_pages_section7.pdf?1588257421).

      , 

      American Heart Association. (Accessed 10 May 2020, at https://cpr.heart.org/-/media/cpr-files/resources/covid-19-resources-for-cpr-training/english/algorithmbls_adult_cacovid_200406.pdf?la=en&hash=553095CDEBE3D215FDE9E45FFC168BD3A0D18C34).

      CPR and chest compressions is an aerosol-generating procedures (AGP),
      • Sorbello M.
      • El-Boghdadly K.
      • Di Giacinto I.
      • et al.
      On behalf of The Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) Airway Research Group, and The European Airway Management Society
      The Italian coronavirus disease 2019 outbreak: experiences and recommendations from clinical practice.
      Anaesthesia. 2020; https://doi.org/10.1111/anae.15049
      , 
      • Ott M.
      • Milazzo A.
      • Liebau S.
      • et al.
      Exploration of strategies to reduce aerosol-spread during chest compressions: a simulation and cadaver model.
      Resuscitation. 2020; https://doi.org/10.1016/j.resuscitation.2020.05.012
      and pose HCP at risk of airborne SARS-CoV2 infection. Currently chest compressions and defibrillation is recomended,

      ERC COVID-19 Guidelines: (Accessed 10 May 2020, at https://www.erc.edu/sites/5714e77d5e615861f00f7d18/content_entry5ea884fa4c84867335e4d1ff/5ea886c54c84867421e4d1fc/files/ERC_covid19_pages_section7.pdf?1588257421).

      , 

      American Heart Association. (Accessed 10 May 2020, at https://cpr.heart.org/-/media/cpr-files/resources/covid-19-resources-for-cpr-training/english/algorithmbls_adult_cacovid_200406.pdf?la=en&hash=553095CDEBE3D215FDE9E45FFC168BD3A0D18C34).

      Rescuers should wear PPE before starting CPR

      American Heart Association. (Accessed 10 May 2020, at https://cpr.heart.org/-/media/cpr-files/resources/covid-19-resources-for-cpr-training/english/algorithmbls_adult_cacovid_200406.pdf?la=en&hash=553095CDEBE3D215FDE9E45FFC168BD3A0D18C34).

      independently on the ventilation interface.
      Fast tracheal intubation, using videolaryngoscope and bougie, in one attempt is recommended.
      • Sorbello M.
      • El-Boghdadly K.
      • Di Giacinto I.
      • et al.
      On behalf of The Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) Airway Research Group, and The European Airway Management Society
      The Italian coronavirus disease 2019 outbreak: experiences and recommendations from clinical practice.
      Anaesthesia. 2020; https://doi.org/10.1111/anae.15049
      In case of failure use of second generation SADs has been claimed to lower aerosol spread,
      • Sorbello M.
      • El-Boghdadly K.
      • Di Giacinto I.
      • et al.
      On behalf of The Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) Airway Research Group, and The European Airway Management Society
      The Italian coronavirus disease 2019 outbreak: experiences and recommendations from clinical practice.
      Anaesthesia. 2020; https://doi.org/10.1111/anae.15049
      , 

      The Faculty of Intensive Care Medicine. Use supraglottic airwyas during the COVID-19 pandemic. ICM Anaesthesia COVID-19. (Accessed 08 May 2020, at https://icmanaesthesiacovid-19.org/use-of-supraglottic-airways-during-the-covid-19-pandemic).

      providing leak-free seal be ensured.
      • Yang W.S.
      • Hou S.W.
      • Lee B.C.
      • et al.
      Taipei Azalea – supraglottic airways (SGA) preassembled with high-efficiency particulate air (HEPA) filters to simplify prehospital airway management for patients with out-of-hospital cardiac arrests (OHCA) during Coronavirus Disease 2019 (COVID-19) pandemic.
      Resuscitation. 2020; 151: 3-5https://doi.org/10.1016/j.resuscitation.2020.03.021
      Solutions with facial or all-body plastic covers have been suggested to reduce aerosolization during airway management, including modifications of SADs,
      • Yang W.S.
      • Hou S.W.
      • Lee B.C.
      • et al.
      Taipei Azalea – supraglottic airways (SGA) preassembled with high-efficiency particulate air (HEPA) filters to simplify prehospital airway management for patients with out-of-hospital cardiac arrests (OHCA) during Coronavirus Disease 2019 (COVID-19) pandemic.
      Resuscitation. 2020; 151: 3-5https://doi.org/10.1016/j.resuscitation.2020.03.021
      but these might be dangerous.
      • (1)
        Positioning the barrier would delay chest compressions and CPR;
      • (2)
        A completely occlusive barrier would limit any SAD's position tests (i.e. drain-tube leak test) and gastric access
        • Sorbello M.
        Evolution of supraglottic airway devices: the Darwinian perspective.
        Minerva Anestesiol. 2018; 84: 297-300
        ;
      • (3)
        Wrapping the patient in a plastic cover would limit further airway maneuver, including fiberoptic-aided intubation through intubatable SAD,
        • Ott M.
        • Milazzo A.
        • Liebau S.
        • et al.
        Exploration of strategies to reduce aerosol-spread during chest compressions: a simulation and cadaver model.
        Resuscitation. 2020; https://doi.org/10.1016/j.resuscitation.2020.05.012
        and would represent a dangerously inflammable pouch full of oxygen in case of defibrillation;
      • (4)
        Wrapping plastic removal is a dangerous maneuver, because of potential airway dislocation (including risk of bucking and coughing), and because of risk of “secondary aerosolization” of its contents upon removal.
        • Laosuwan P.
        • Earsakul A.
        • Pannangpetch P.
        • Sereeyotin J.
        Acrylic box vs. plastic sheet covering on droplet dispersal during extubation in COVID-19 patients.
        Anesth Analg. 2020; https://doi.org/10.1213/ANE.0000000000004937
      In lack of evidence, and facing the risk that use of similar devices may generate a false sense of security among HCPs, we strongly recommend to stay with well elaborated guidelines and to use certified airborne-level PPE during CPR and airway management.

      ERC COVID-19 Guidelines: (Accessed 10 May 2020, at https://www.erc.edu/sites/5714e77d5e615861f00f7d18/content_entry5ea884fa4c84867335e4d1ff/5ea886c54c84867421e4d1fc/files/ERC_covid19_pages_section7.pdf?1588257421).

      , 

      American Heart Association. (Accessed 10 May 2020, at https://cpr.heart.org/-/media/cpr-files/resources/covid-19-resources-for-cpr-training/english/algorithmbls_adult_cacovid_200406.pdf?la=en&hash=553095CDEBE3D215FDE9E45FFC168BD3A0D18C34).

      , 
      • Sorbello M.
      • El-Boghdadly K.
      • Di Giacinto I.
      • et al.
      On behalf of The Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) Airway Research Group, and The European Airway Management Society
      The Italian coronavirus disease 2019 outbreak: experiences and recommendations from clinical practice.
      Anaesthesia. 2020; https://doi.org/10.1111/anae.15049
      , 
      • Ott M.
      • Milazzo A.
      • Liebau S.
      • et al.
      Exploration of strategies to reduce aerosol-spread during chest compressions: a simulation and cadaver model.
      Resuscitation. 2020; https://doi.org/10.1016/j.resuscitation.2020.05.012
      , 

      The Faculty of Intensive Care Medicine. Use supraglottic airwyas during the COVID-19 pandemic. ICM Anaesthesia COVID-19. (Accessed 08 May 2020, at https://icmanaesthesiacovid-19.org/use-of-supraglottic-airways-during-the-covid-19-pandemic).

      Funding (no external funding for this article)
      Conflicts of interest/Competing interests MS has received paid consultancy from Teleflex Medical, Verathon Medical and DEAS Italia, is a patent co-owner (no royalties) of DEAS Italia and has received lecture grants and travel reimbursements from MSD Italia. IDG has received lecture grants and travel reimbursements from MSD Italia. SF declares no competing interest. RG is ERC Director if Training and Education, ILCOR Task Force Chair on Education, Implementation, Teams.

      Ethics approval

      Not applicable.

      Consent to participate

      Not applicable.

      Consent for publication

      Not applicable.

      Authors’ contributions

      MS idea and writing of manuscript draft; IDG critical appraisal, writing final manuscript; SF literature check and critical appraisal, writing final manuscript; RG final review, writing final manuscript.

      References

        • Scapigliati A.
        • Gullì A.
        • Semeraro F.
        • et al.
        How to ventilate during CPR in time of Covid-19?.
        Resuscitation. 2020; (pii: S0300-9572(20)30174-X)https://doi.org/10.1016/j.resuscitation.2020.04.036
        View in Article

      2. ERC COVID-19 Guidelines: (Accessed 10 May 2020, at https://www.erc.edu/sites/5714e77d5e615861f00f7d18/content_entry5ea884fa4c84867335e4d1ff/5ea886c54c84867421e4d1fc/files/ERC_covid19_pages_section7.pdf?1588257421).

        View in Article

      3. American Heart Association. (Accessed 10 May 2020, at https://cpr.heart.org/-/media/cpr-files/resources/covid-19-resources-for-cpr-training/english/algorithmbls_adult_cacovid_200406.pdf?la=en&hash=553095CDEBE3D215FDE9E45FFC168BD3A0D18C34).

        View in Article
        • Sorbello M.
        • El-Boghdadly K.
        • Di Giacinto I.
        • et al.
        • On behalf of The Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) Airway Research Group, and The European Airway Management Society
        The Italian coronavirus disease 2019 outbreak: experiences and recommendations from clinical practice.
        Anaesthesia. 2020; https://doi.org/10.1111/anae.15049
        View in Article
        • Ott M.
        • Milazzo A.
        • Liebau S.
        • et al.
        Exploration of strategies to reduce aerosol-spread during chest compressions: a simulation and cadaver model.
        Resuscitation. 2020; https://doi.org/10.1016/j.resuscitation.2020.05.012
        View in Article

      6. The Faculty of Intensive Care Medicine. Use supraglottic airwyas during the COVID-19 pandemic. ICM Anaesthesia COVID-19. (Accessed 08 May 2020, at https://icmanaesthesiacovid-19.org/use-of-supraglottic-airways-during-the-covid-19-pandemic).

        View in Article
        • Yang W.S.
        • Hou S.W.
        • Lee B.C.
        • et al.
        Taipei Azalea – supraglottic airways (SGA) preassembled with high-efficiency particulate air (HEPA) filters to simplify prehospital airway management for patients with out-of-hospital cardiac arrests (OHCA) during Coronavirus Disease 2019 (COVID-19) pandemic.
        Resuscitation. 2020; 151: 3-5https://doi.org/10.1016/j.resuscitation.2020.03.021
        View in Article
        • Sorbello M.
        Evolution of supraglottic airway devices: the Darwinian perspective.
        Minerva Anestesiol. 2018; 84: 297-300
        View in Article
        • Laosuwan P.
        • Earsakul A.
        • Pannangpetch P.
        • Sereeyotin J.
        Acrylic box vs. plastic sheet covering on droplet dispersal during extubation in COVID-19 patients.
        Anesth Analg. 2020; https://doi.org/10.1213/ANE.0000000000004937
        View in Article

      Article info

      Publication history

      Published online: June 03, 2020
      Received: May 15, 2020

      Identification

      DOI: https://doi.org/10.1016/j.resuscitation.2020.05.043

      Copyright

      © 2020 Elsevier B.V. All rights reserved.

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