”The question remains to be answered as to whether the hard lessons we have learned during the pandemic will help us to face and overcome future global healthcare challenges.
When the first cases of the SARS-CoV-2 virus in Wuhan, China were made public in December 2019, few people dreamt of the changes this would mean for their lives. For many it would mean a tedious “lock-down” at home, with remote working, online schooling, and an abrupt stop to recreational and social activities. For others, consequences would include forced separation from family and friends, job loss, and financial hardship. And for many others, it would mean losing a loved one, serious illness, new disability, or even death. The COVID-19 pandemic has changed people’s lives, habits, and customs worldwide – and healthcare workers and hospital procedures are no exception, with PPE, limited visits, and stricter procedural guidelines becoming part of a new normal. The question remains to be answered as to whether the hard lessons we have learned during the pandemic will help us to face and overcome future global healthcare challenges.
One of the procedures that has attracted much attention from the media and undergone specific changes because of the pandemic is endotracheal intubation (ETI). This procedure is a life-saving technique in which an endotracheal (“breathing”) tube is inserted into a patient’s airway in order to provide oxygen and ventilation. ETI is the third most common hospital procedure worldwide, with more than 50 million intubations carried out per year globally. ETI takes place in many scenarios in medical practice, from general anesthesia before and during surgery, to emergency intubation in patients with severe respiratory failure, enabling these patients to be connected to a ventilator. In particular, during the COVID-19 pandemic, ETI has become one of the mainstays of therapy in critical patients.
“Timely, but not premature, intubation is crucial”, concludes a study on intubation in COVID-19 published in Anesthesiology[i]. However, the dangers of ETI in COVID-19 patients are high, not only for the patients themselves but also for the clinicians who perform the procedure, as ETI is an aerosol-generating procedure which puts healthcare workers at risk for infection. In a study published in Anesthesia[ii], over 10% of intubations resulted in a healthcare professional showing signs of SARS-CoV-2 infection. A worrying finding from this report is that 87.2% of the clinicians who became infected during intubation were wearing correct personal protective equipment as recommended by the World Health Organization (compared with 87.8% of clinicians who did not become infected).
Various protocols have been issued by national and international societies in order to reduce the risk of SARS-CoV-2 transmission during ETI. For example, the joint statement issued by the Safe Airway Society of Australia and New Zealand and the Australian and New Zealand Intensive Care Society aims to ensure “first pass success, secure the airway rapidly and minimize risks to staff”[iii] through the appropriate use of personal protective equipment, negative pressure rooms (where available), intensive training and early intervention. These protocols point out the importance of avoiding aerosol exposure so as to avoid new cases of COVID-19 in healthcare workers.
Interestingly enough, the SARS-CoV-2 virus isn’t the only pathogen to pose a potential risk to anesthetists and intensive care doctors during ETI. Other aerosol-borne viruses, such as influenza, can also cause respiratory failure and lead to the need for intubation (around 8% of hospitalized patients[iv]). In fact, influenza is a big concern for health systems worldwide, with over 38,000,000 cases, 400,000 hospitalizations and 20,000 deaths in 2019 in the USA alone[v]. Although effective influenza vaccines exist, the virus’ high potential for mutations makes it a constant threat for public health. In a 2009 report, Dr. Tellier from the Provincial Laboratory for Public Health of Alberta, Canada, commented that “concerns about an influenza pandemic have been recently rekindled by the emergence in southeast Asia of highly pathogenic strains of avian influenza A (H5N1) with pandemic potential”, going on to underline that “the mode of transmission that, arguably, has the greatest impact for infection control is aerosol transmission since it requires specialized personal protective equipment (PPE), e.g., N95 respirators, and procedures.”[vi] Although infection by this particular strain of avian influenza did not reach pandemic levels, in hindsight, Dr. Tellier’s words seem almost prophetic in the light of the present COVID-19 pandemic, highlighting the importance of preparing for and protecting against aerosol-related transmission as a means to achieving infection control where respiratory pathogens are concerned.
At Airway ShieldTM, we strive to provide a solution that minimizes the risk of transmission of aerosol-borne pathogens during ETI – filling the gap which personal protective equipment fails to cover – while enabling clinicians to secure the airway with first pass success. Although Airway ShieldTM was initially conceived as a response to the COVID-19 pandemic, increased scientific awareness about the risks of aerosol transmission points to an important role for our technology for critical patients with other common, potentially life-threatening, respiratory infections.
We are excited to be part of the answer to present – and future – global healthcare challenges in respiratory medicine and critical care. As US health economist Gail Wilensky said, “When you’re forced to find different ways of doing things and you find out they are easier and more efficient, it’s going to be hard to go back to the old way.”[vii]
[i] Meng, L., Qiu, H., Wan, L., Ai, Y., Xue, Z., Guo, Q., … & Xiong, L. (2020). Intubation and ventilation amid the COVID-19 outbreak: Wuhan’s experience. Anesthesiology, 132(6), 1317-1332.
[ii] El‐Boghdadly, K., Wong, D. J. N., Owen, R., Neuman, M. D., Pocock, S., Carlisle, J. B., … & Ahmad, I. (2020). Risks to healthcare workers following tracheal intubation of patients with COVID‐19: a prospective international multicentre cohort study. Anaesthesia.
[iii] Brewster, D. J., Chrimes, N. C., Do, T. B., Fraser, K., Groombridge, C. J., Higgs, A., … & Gatward, J. J. (2020). Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. Med J Aust, 16.
[iv] Donnino, M. W., Moskowitz, A., Thompson, G. S., Heydrick, S. J., Pawar, R. D., Berg, K. M., … & v Grossestreuer, A. (2020). Comparison Between Influenza and COVID-19 at a Tertiary Care Center. medRxiv.
[v] https://www.cdc.gov/flu/about/burden/index.html
[vi] Tellier, R. (2009). Aerosol transmission of influenza A virus: a review of new studies. Journal of the Royal Society Interface, 6(suppl_6), S783-S790.
[vii] Julie Rovner. Health System Changes Spurred by COVID May Be Here to Stay – Medscape – Jun 09, 2020.