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Quick Take: Airway management lessons learned for COVID-19 patients

EMS grand rounds presentation focuses on proper PPE, endotracheal intubation and infection control


Recommendations and the overall COVID-19 pandemic itself are changing rapidly so it is important to stay up to date with the most recent guidelines and recommendations.

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EMS and first responders are on the front lines of the COVID-19 pandemic and it is important that they are protected while performing their job. Several Seattle area physicians affiliated with the University of Washington, including Dr. Thomas Rea and Dr. Michael Sayre, presented information regarding how EMS can protect themselves from coronavirus exposure while intubating potential COVID-19 patients.

Sayre began the UWashEMS Fellowship Grand Rounds online presentation with an overview of the current situation in Seattle and how they are handling the outbreak while Drs. Latimer, Murphy and Sharar shared information they have gathered from colleagues around the world and various professional guidelines for COVID-19 patient management.

Top quotes on COVID-19 patient management

Here are four memorable quotes about PPE, airway management and exposure control.

“PPE is effective in this illness, that comes from some first-hand discussions with the world’s experts on the coronavirus.”

— Dr. Thomas Rea, Internal Medicine physician at Harborview Medical Center and Medical Director of King County EMS.

“In summary, the data I’ve been able to find and the guidelines that I’ve been able to find favor the use of an ET tube over an LMA for good clinical reasons for the patient as well as good protective reasons for a host of providers who are involved in the care of that patient. And especially when proper PPE is being used.”

— Dr. Samuel Sharar, Pediatric Anesthesiologist at the Harborview Medical Center in Seattle, WA.

“Every day is a new learning lesson, we continue to take a look at the exposures to our workers and how much of a dose of the virus they are receiving and these things are related to how close they are to the patient and how much time they’re spending with that patient and the kind of care they are receiving.”

— Dr. Michael Sayre, Emergency Medicine physician at Harborview Medical Center and the Seattle Fire Department Medical Director.

“The rest of the country is looking to you guys and what you’re doing every day and they’re quite impressed.”

— Dr. Sayre (speaking to Washington first responders)

Top takeaways on COVID-19 patient management

The full video of the presentation is available for viewing at Meanwhile, here are four top takeaways for EMTs, paramedics and other healthcare providers for COVID-19 patient assessment and care

1. Use full PPE during airway management procedures

PPE is an effective and important way to prevent healthcare workers from contracting COVID-19. Wear full PPE when securing airways on known or suspected COVID-19 patients:

  • N95 mask
  • Gown
  • Gloves
  • Eyewear or face shield

The recently published NEJM article, “Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARAS-CoV-1,” found that COVID-19 acts similarly to the SARS 1 virus which had an outbreak in the early 2000s. They found that the aerosolized virus has a half-life of about 1 hour and believe N95 masks will adequately protect healthcare workers. Experts agree that surgical masks are insufficient for use during potential aerosolizing procedures such as BVM ventilation, endotracheal intubation, and CPAP/Bi-PAP when treating a known or suspected COVID-19 patient.

Regarding concerns about conserving PPE, King County EMS agencies have one to two responders dress in full PPE in cases where the patient is unlikely to be infected with COVID-19. These initial providers evaluate the patient to determine whether the whole crew needs to don full PPE before treating the patient. They have found this to be effective in protecting providers and conserving PPE resources.

2. Endotracheal intubation superior to laryngeal mask airway

ET intubation is preferable to LMA placement, regardless of the patient’s suspected COVID-19 status, because it allows the provider to deliver positive pressure ventilation, decreases the risk of aspiration and only exposes one provider to potentially aerosolized virus particles. That being said, LMAs should still be used in the case of failed intubation. Additionally, proper PPE must be worn while performing any airway management procedures.

When possible, rapid sequence intubation should be performed in well-ventilated environments, such as outdoors, to help reduce the risk of infection.


3. Proper seal prevents aerosolization

Ensure an adequate seal with any device – BVM, LMA or ETT – to reduce the risk of aerosolized virus escaping with exhalation and exposing those around the patient. Patients who have inadequate seals have the potential to infect those around them, not only those currently in the vicinity those that they come into contact while they are transported to and inside the hospital.

4. Airway management practices are changing as more is learned

We are still learning about the virus and what practices are effective for assessing and treating patients. There is a limited amount of data and literature regarding SARS and COVID-19 making it difficult to know exactly what procedures cause aerosolization and what practices are most effective in protecting providers. Recommendations and the overall COVID-19 pandemic itself are changing rapidly so it is important to stay up to date with the most recent guidelines and recommendations.

Additional resources for COVID-19 patient management

Learn more about airway management, PPE and best practices when treating COVID-19 patients with these resources:

Marianne Meyers, BS, is a third-year medical student at the University of Washington School of Medicine interested in pursuing emergency medicine. Previously, she was a member of the Santa Clara University collegiate EMS squad where she received her B.S. in Public Health Science. Additionally, she has worked with the King County Public Health Department in Seattle, Washington studying EMT naloxone administration.