Clinical recommendations for in-hospital airway management during aerosol-transmitting procedures in the setting of a viral pandemic

Removal of Contaminated Personal Protective Equipment With and Without Supervision. A Randomized Crossover Simulation-Based Study

INTRODUCTION

Personal protective equipment (PPE) reduces the risk of pathogens reaching the skin and clothing of health care personnel. We hypothesize that doffing PPE following verbal instructions by a supervisor is more effective in reducing contamination compared with doffing without verbal instructions. Our primary aim was to determine contamination rates with and without supervised doffing. The secondary aim was to determine the number and localization of contaminated body sites and PPE removal times in both groups.

METHODS

Staff members of Bnai Zion Medical Center participated in this single-center, randomized simulation study (NCT05008627). Using a crossover design, all participants donned and doffed the PPE twice, once under guidance from a trained supervisor and then independently without supervision (group A), or vice versa (group B). Participants were randomized to either group A or B using a computer-generated random allocation sequence. The PPE was "contaminated" with Glo Germ on the thorax, shoulders, arms, hands, legs, and face shield. After doffing the PPE, the participant was examined under ultraviolet light to detect traces of contamination. The following variables were collected: contamination rates, the number and localization of contaminated body sites, and PPE doffing time.

RESULTS

Forty-nine staff members were included. In group A, the contamination rate was significantly lower (8% vs. 47%; χ 2 = 17.19; p < 0.001). The sites most frequently contaminated were the neck and hands. Mean PPE doffing time under verbal instructions was significantly longer [mean (SD): 183.98 (3.63) vs. 68.43 (12.75) seconds, P < 0.001] compared with unsupervised doffing.

CONCLUSIONS

In a simulated setting, PPE doffing following step-by-step verbal instructions from a trained supervisor reduces the rate of contamination but prolongs doffing time. These findings could have important implications for clinical practice and could further protect health care workers against contamination from emerging and high-consequence pathogens.

Approach to the Physiologically Challenging Endotracheal Intubation in the Intensive Care Unit

Endotracheal intubation for airway management is a common procedure in the ICU. Intubation may be difficult due to anatomic airway abnormalities but also due to physiologic derangements that predispose patients to cardiovascular collapse during the procedure. Results of studies demonstrate a high incidence of morbidity and mortality associated with airway management in the ICU. To reduce the likelihood of complications, medical teams must be well versed in the general principles of intubation and be prepared to manage physiologic derangements while securing the airway. In this review, we present relevant literature on the approach to endotracheal intubation in the ICU and provide pragmatic recommendations relevant to medical teams performing intubations in patients who are physiologically unstable.

Development of an emergency airway response system for COVID-19 at a tertiary care hospital in resource limited country

The ongoing coronavirus (COVID-19) infection causes severe respiratory dysfunction and has become an emergent issue for worldwide healthcare due to highly transmissible and contagious nature. Aerosol generating procedures such as tracheal intubation is of particularly high risk. This mandates some advice on processes and techniques required to protect staff and uniform approach during airway management. We hereby share our experience in development of an emergency response system to deal with COVID airway management at a frontline hospital which particularly consider the local demands and resources. This includes a change in working dynamics with 24/7 consultant coverage for emergent or urgent tracheal intubation of COVID patients at non-operating room locations. Other steps include prepackaging intubation baskets, availability of videolaryngoscope, standard personal protective equipment including powered air purifying respirator, and use of modified intubation checklist.

Combining the advantages of AlexNet convolutional deep neural network optimized with anopheles search algorithm based feature extraction and random forest classifier for COVID-19 classification

In this article, COVID-19 detection and classification framework based on anopheles search optimized AlexNet convolutional deep neural network for random forest classifier is implemented. Here, the COVID-19 dataset is taken from Joseph Paul Cohen database. Then, the input images are preprocessed with the help of fuzzy gray level difference histogram equalization technique (FGLHE) and fuzzy stacking technique for color enhancement and noise elimination in the input images. The FGLHE technique and fuzzy stacking technique are combined together and forms into stacked dataset image. This stacked dataset are trained with AlexNet convolutional deep neural network model and the feature packages acquired via the models are processed by the anopheles search algorithm. Subsequently, the efficient features are combined and delivered to random forest (RF) classifier. The proposed approach is implemented in MATLAB. The proposed ADCNN-ASA-RFC provides 91.66%, 69.13%, 34.86%, and 70.13% higher accuracy, 79.13%, 60.33%, and 63.34% higher specificity and 77.13%, 58.45%, 25.86%, and 55.33%, higher sensitivity compared with existing algorithms. At last, the simulation outcomes demonstrate that the proposed system can be able to find the optimal solutions efficiently and accurately with COVID-19 diagnosis.

High flow nasal cannula oxygenation in COVID-19 related acute respiratory distress syndrome: a safe way to avoid endotracheal intubation?

BACKGROUNDS

High flow nasal cannula (HFNC) is an alternative therapy for acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). This study aimed first to describe outcomes of patients suffering from COVID-19-related ARDS treated with HFNC; secondly to evaluate safety of HFNC (patients and healthcare workers) and compare patients according to respiratory outcome.

METHODS

A retrospective cohort was conducted in French general hospital intensive care unit (ICU). Patients were included if receiving HFNC for hypoxemia (saturation pulse oxygen (SpO2) <92% under oxygen ⩾6 L/min) associated with ARDS and positive SARS-CoV-2 polymerase chain reaction (PCR). Main clinical characteristics and outcomes are described in patients: (a) with do not intubate order (HFNC-DNIO); (b) who did not need intubation (HFNC-only); and (c) eventually intubated (HFNC-intubation). Medians are presented with (1st-3rd) interquartile range.

RESULTS

From 26 February to 30 June 2020, 46 patients of median age 75 (70-79) years were included. In the HFNC-DNIO group (n = 11), partial arterial oxygen pressure (PaO2)/inhaled fraction of oxygen (FiO2) ratio median worst PaO2/FiO2 ratio was 109 (102-172) and hospital mortality was 54.5%. Except the HFNC-DNIO patients (n = 35), 20 patients (57%) were eventually intubated (HFNC-intubation group) and 15 were only treated by HFNC (HFNC-only). HFNC-intubation patients presented higher worst respiratory rates per minute in ICU [37 (34-41) versus 33 (24-34) min, p < 0.05] and worsened ICU admission PaO2/FiO2 ratios [121 (103-169) versus 191 (162-219), p < 0.001] compared with HFNC-only patients. Hospital mortality was 35% (n = 7/20) in HFNC-intubation group, 0% in HFNC-only group with a global mortality of these two groups of 20% (n = 7/35). Among tests performed in healthcare workers, 1/12 PCR in symptomatic healthcare workers and 1.8% serologies in asymptomatic healthcare workers were positive. After review of each case, COVID-19 was likely to be acquired outside hospital.

CONCLUSIONS

HFNC seems to be useful for COVID-19-related ARDS and safe for healthcare workers. ARDS severity with PaO2/FiO2 <150 associated with respiratory rate >35/min could be regarded as a predictor of intubation.The reviews of this paper are available via the supplemental material section.