To the Editor,

Airway management may expose healthcare workers (HCWs) to the risk of contracting coronavirus disease (COVID-19).1 This exposure may occur in a broad range of clinical scenarios, from intubation of asymptomatic individuals undergoing elective surgery to emergent airway management for COVID-19-related respiratory failure. While efforts have been made to assess the magnitude of this risk, definitive data are lacking, and variability may exist across different settings and countries.

A prospective, international, quality improvement project (intubateCOVID; https://www.intubatecovid.org/info) was launched to collect information on HCWs involved in tracheal intubation of patients with suspected or confirmed COVID-19.2 A waiver of formal research ethics approval was obtained from the Ottawa Health Science Network Research Ethics Board on 31 March 2020. Participants reported details of airway management, personal health outcomes, personal protective equipment used, and personnel involved. Intubation reports predating enrolment were permitted. We present the Canadian data from this international registry and discuss their implications.

From 3 March to 7 August 2020, 54 HCWs (37 males and 17 females; median [interquartile range (IQR)] age 41 [37–48] years; majority anesthesiologists) from 37 Canadian hospitals registered at least one tracheal intubation in a COVID-19 patient and subsequently recorded their own COVID-19 infection status. Overall, 136 tracheal intubations in COVID-19 patients (44 confirmed and 92 suspected) were reported (median [IQR] intubations per participant, 2 [1–2]). The Table summarizes the details. Participants were the primary intubator in most procedures. Respiratory failure was the main indication for intubation and 75% were performed in the intensive care unit or emergency department. Rapid sequence induction was most commonly employed, a videolaryngoscope was the first-line device, and there was a high first-attempt success rate. Two emergency front-of-neck airways (eFONA) were reported (one in the resuscitation of a cardiac arrest, where eFONA was performed after two failed videolaryngoscopy attempts, and another where FONA was the first airway attempt in a patient with laryngeal trauma from a stab injury).

Table 1 Details of tracheal intubations in COVID-19 patients for Canadian participants in the intubateCOVID registry from 3 March to 7 August 2020
Full size table

Laboratory-confirmed COVID-19 was reported in one HCW five days after the intubation (1/54 HCWs, 1.9%; one HCW/136 intubations, 0.7%). Two HCWs self-isolated because of symptoms (but subsequently tested negative for COVID-19) six and 23 days after the intubation, respectively (2/54 HCWs, 3.7%; 2 HCWs/136 intubations, 1.5%). Personal protective equipment (PPE) was widely used, but World Health Organization recommended standards3 were not met in five procedures (all occurring in March and April; reasons for these safety breaches could not be ascertained). The recommendation of minimizing the number of HCWs in the room to mitigate risk exposure4,5 was broadly followed (median [IQR] 3 [3–4]), but up to 10–12 individuals were present in two intubations (details of these events were not available).

Minimizing unnecessary HCW exposure remains an important focus and establishing dedicated airway response teams may help in this regard. Our findings should be interpreted within the limitations of a voluntary self-reported registry. The data undoubtedly represent only a small sample of COVID-19-related intubations performed in Canada, and a causal link between participation in airway management and subsequent COVID-19 infection cannot be ascertained. At the time of writing, Canada is into its second wave of COVID-19 infections, and data from continued participation in registries such as intubateCOVID will be valuable in guiding healthcare management policies.