Ummary of 20 tracheal intubation by anesthesiologists for patients with severe COVID-19 pneumonia

Existing evidences in COVID 19 shows that the elderly patients with some chronic diseases have a poor prognosis, and these patients are most likely to develop into critically ill pneumonia. Improving oxygenation and lung protection is the core of multi-organ function supportive treatment for this type of patients. Tracheal intubation for mechanical ventilation is an important pulmonary ventilation strategy. We retrospectively reviewed medical charts of 20 critically ill patients with Covid-19 pneumonia who require tracheal intubation from February 17 to March 19 in Wuhan No.1 hospital, China. We collected their demographics, vital signs, blood gas analysis before and after tracheal intubation, and 7-day outcome after tracheal intubation. Among respiratory therapy used for patients with respiratory failure, high flow nasal cannula (HFNC), noninvasive positive pressure ventilation (NPPV) and tracheal intubation mechanical ventilation was applied for patients with SARS-CoV-2 pneumonia who develop ARDS. Although NPPV is the main treatment method for many patients with COVID-19 and ARDS, but it did not dramatically improve the overall outcome. A retrospective study of patients with critically ill adult SARS-CoV-2 pneumonia (28-day mortality 61.5%) showed that among 29 (56%) out of 52 patients who had received NPPV, 16 were changed to invasive mechanical ventilation and eventually 23 were died. For patients with SARS-CoV-2 and ARDS, if the disease continues to deteriorate during HFNC or NPPV treatment, earlier switch to tracheal intubation should be considered. After tracheal intubation, a protective lung ventilation strategy is usually applied, i.e. small tidal volume (4–8 ml/kg ideal weight) and low inspiratory pressure (plateau pressure < 30 cm H2O), to reduce ventilator-related lung injury. Studies show that the widespread implementation of protective ventilation strategies reduced the incidence of barotrauma in critically ill patients to 2%, which is much lower than 25% during SARS-CoV pneumonia. When the patient’s ROX index < 2.85 or SpO2 < 93% and the RR > 35 times/min, the patient gasps and cannot speak whole sentences when lying in bed, this indicates that the success rate of HFNC is low, and switch to tracheal intubation should be considered. When using NPPV, if the patient’s respiratory distress does not improve, RR > 35 times/min, Vt > 9 ml/kg, NPPV should be terminated and the tracheal intubation should be considered regardless of the oxygen saturation. Although both survivors and non-survivors showed significant improvement in their oxygenation and CO2 retention after tracheal intubation , non-survivors showed significantly worse blood gas analysis results compared to survivors before and after tracheal intubation. Nevertheless, our observational analysis of 20 consecutive cases shows non-survivors 7-day after tracheal intubation showed significantly worse blood gas data compared with survivors, indicating earlier tracheal intubation before the blood gas data deterioration may be associated with a better outcome. To read more- https://link.springer.com/article/10.1007%2Fs00540-020-02778-8

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