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

      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?.
      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. 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.
      • Ott M.
      • Milazzo A.
      • Liebau S.
      • et al.
      Exploration of strategies to reduce aerosol-spread during chest compressions: a simulation and cadaver model.
      and pose HCP at risk of airborne SARS-CoV2 infection. Currently chest compressions and defibrillation is recomended, Rescuers should wear PPE before starting CPR 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.
      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.

      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.
      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.
      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.
        ;
      • (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.
        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.
      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.
      • 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.
      • Ott M.
      • Milazzo A.
      • Liebau S.
      • et al.
      Exploration of strategies to reduce aerosol-spread during chest compressions: a simulation and cadaver model.

      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.

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        • Gullì A.
        • Semeraro F.
        • et al.
        How to ventilate during CPR in time of Covid-19?.
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        • 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.
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        • Milazzo A.
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        Exploration of strategies to reduce aerosol-spread during chest compressions: a simulation and cadaver model.
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        • 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.
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        Evolution of supraglottic airway devices: the Darwinian perspective.
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        • Sereeyotin J.
        Acrylic box vs. plastic sheet covering on droplet dispersal during extubation in COVID-19 patients.
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