Severe acute respiratory syndrome-corona virus-2, which causes coronavirus disease 2019 (COVID-19), is highly contagious. Airway management of patients with COVID-19 is high risk to staff and patients. We aimed to develop principles for airway management of patients with COVID-19 to encourage safe, accurate and swift performance. This consensus statement has been brought together at short notice to advise on airway management for patients with COVID-19, drawing on published literature and immediately available information from clinicians and experts. Recommendations on the prevention of contamination of healthcare workers, the choice of staff involved in airway management, the training required and the selection of equipment are discussed. The fundamental principles of airway management in these settings are described for: emergency tracheal intubation; predicted or unexpected difficult tracheal intubation; cardiac arrest; anaesthetic care; and tracheal extubation. We provide figures to support clinicians in safe airway management of patients with COVID-19. The advice in this document is designed to be adapted in line with local workplace policies.

Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists.

The potential aerosolised transmission of severe acute respiratory syndrome coronavirus-2 is of global concern. Airborne precaution personal protective equipment and preventative measures are universally mandated for medical procedures deemed to be aerosol generating. The implementation of these measures is having a huge impact on healthcare provision. There is currently a lack of quantitative evidence on the number and size of airborne particles produced during aerosol-generating procedures to inform risk assessments. To address this evidence gap, we conducted real-time, high-resolution environmental monitoring in ultraclean ventilation operating theatres during tracheal intubation and extubation sequences. Continuous sampling with an optical particle sizer allowed characterisation of aerosol generation within the zone between the patient and anaesthetist. Aerosol monitoring showed a very low background particle count (0.4 particles.l-1 ) allowing resolution of transient increases in airborne particles associated with airway management. As a positive reference control, we quantitated the aerosol produced in the same setting by a volitional cough (average concentration, 732 (418) particles.l-1 , n = 38). Tracheal intubation including facemask ventilation produced very low quantities of aerosolised particles (average concentration, 1.4 (1.4) particles.l-1 , n = 14, p < 0.0001 vs. cough). Tracheal extubation, particularly when the patient coughed, produced a detectable aerosol (21 (18) l-1 , n = 10) which was 15-fold greater than intubation (p = 0.0004) but 35-fold less than a volitional cough (p < 0.0001). The study does not support the designation of elective tracheal intubation as an aerosol-generating procedure. Extubation generates more detectable aerosol than intubation but falls below the current criterion for designation as a high-risk aerosol-generating procedure. These novel findings from real-time aerosol detection in a routine healthcare setting provide a quantitative methodology for risk assessment that can be extended to other airway management techniques and clinical settings. They also indicate the need for reappraisal of what constitutes an aerosol-generating procedure and the associated precautions for routine anaesthetic airway management.

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A quantitative evaluation of aerosol generation during tracheal intubation and extubation.

Background Emergence coughing can harm the patient following completion of surgery, but it is unclear which medication is most effective at reducing this event. We conducted a systematic review and network meta-analysis of RCTs to determine the medications' relative efficacies on decreasing moderate to severe emergence coughing after general anaesthesia. Medications studied were lidocaine (i.v., intracuff, topical, or tracheal application), dexmedetomidine, remifentanil, and fentanyl. Methods We searched eight different medical literature databases, conference abstracts, and article references. After screening, included citations were evaluated for bias and had their data extracted. Pooled odds ratios and 95% confidence intervals for each treatment comparison were calculated. A surface under the cumulative ranking curve analysis (SUCRA) determined the relative rank of each intervention to decrease moderate to severe emergence coughing. Subgroup analyses included severe coughing only, extubation times, type of maintenance anaesthetic, and dosages. Results The network meta-analysis included 70 studies and 5286 patients. All study medications had favourable odds in reducing moderate and severe peri-extubation coughing compared with either no medication or placebo. No single medication was favoured over another. Dexmedetomidine had the highest SUCRA rank, followed in order by remifentanil, fentanyl, and lidocaine via intracuff, tracheal/topical, and i.v. routes. Remifentanil was ranked highest for decreasing severe coughing only. Intracuff lidocaine had higher odds of prolonging extubation times compared with placebo, dexmedetomidine, fentanyl, and remifentanil. Conclusion All study medications were better than placebo or no medication in reducing moderate to severe emergence cough, with dexmedetomidine ranked the most effective. Systematic review registration PROSPERO registration number: CRD42018102870.

Medications to reduce emergence coughing after general anaesthesia with tracheal intubation: a systematic review and network meta-analysis.

Risk to healthcare workers treating asymptomatic patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the operating room depends on multiple factors. This review examines the evidence for asymptomatic or pre-symptomatic carriage of SARS-CoV-2, the risk of transmission from asymptomatic patients, and the specific risks associated with aerosol-generating procedures. Protective measures, such as minimization of aerosols and use of personal protective equipment in the setting of treating asymptomatic patients, are also reviewed. We examined the published literature as well as Societal guidelines. There is evidence that a proportion of those infected with SARS-CoV-2 have detectable viral loads prior to exhibiting symptoms, or without ever developing symptoms. The degree of risk of transmission from asymptomatic patients to healthcare providers will depend on the prevalence of disease in the population, which is difficult to assess without widespread population screening. Aerosol-generating procedures increase the odds of viral transmission from infected symptomatic patients to healthcare providers, but transmission from asymptomatic patients has not been reported. Techniques to minimize aerosolization and appropriate personal protective equipment may help reduce the risk to healthcare workers in the operating room. Some societal guidelines recommend the use of airborne precautions during aerosol-generating procedures on asymptomatic patients during the coronavirus disease pandemic, although evidence supporting this practice is limited. Viral transmission from patients exhibiting no symptoms in the operating room is plausible and efforts to reduce risk to healthcare providers include reducing aerosolization and wearing appropriate personal protective equipment, the feasibility of which will vary based on geographic risk and equipment availability.

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Asymptomatic carriage and transmission of SARS-CoV-2: What do we know?

Extubation of patients with COVID-19.

Emergence coughing and bucking, secondary to endotracheal tube stimulation of the tracheal mucosa, frequently occurs after the general anesthetic recedes. Besides general unpleasantness, coughing has important physiological sequelae that may be detrimental to the postoperative patient. Multiple pharmacological strategies have been published, but prior systematic reviews on this topic have neither been comprehensive enough in their literature or medication search, nor provided us the answer regarding what the best pharmacological method is to prevent or minimize peri-extubation coughing. Our systematic review and network meta-analysis’ primary objective is to determine the relative efficacies of different pharmacological methods on decreasing coughing (none to mild compared to moderate to severe, as defined by the modified Minogue scale) during emergence after a general anesthetic with endotracheal intubation in adult elective surgeries. Medications of interest are lidocaine or lignocaine (intravenous (IV), intracuff alkalinized, intracuff non-alkalinized, topical, endotracheal application), dexmedetomidine IV, remifentanil IV, and fentanyl IV. These medications were selected based on a preliminary review of the literature. Using a predefined search strategy, we will search MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, and the Cochrane Methodology Register, with no date or language restrictions. Gray literature search will encompass conference abstracts, Web of Science, and references from publications selected for full-text review. Two reviewers will independently screen the retrieved literature using predetermined inclusion criteria, process publications selected for full-text review, extract data from publications chosen for study inclusion, and evaluate for bias using the Cochrane risk of bias assessment. Risk ratios and 95% confidence intervals will be calculated for each study, and a surface under the cumulative ranking curve will determine the relative rank of each intervention in its ability to prevent coughing on emergence. The proposed systematic review and network meta-analysis will not only provide a more thorough review of common medications used to decrease emergence coughing, but also inform clinicians which of these pharmacological strategies is the best approach. PROSPERO CRD42018102870

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Pharmacological methods for reducing coughing on emergence from elective surgery after general anesthesia with endotracheal intubation: protocol for a systematic review of common medications and network meta-analysis

Objective This study sought to identify factors independently associated with a negative impression of the medical profession in patients with endometriosis who were presenting to a tertiary referral centre. Methods A cross-sectional analysis was conducted on a prospective data registry between December 2013 and June 2017 at a tertiary referral centre for pelvic pain and endometriosis. The main outcome variable, negative impression about the medical profession, was measured with the four-item subscale of the Endometriosis Health Profile-30 and divided into three groups: no (0), some (1–8), and many (9–16) negative impressions. Patients with a surgical and histological diagnosis of endometriosis were included. Postmenopausal women were excluded. Bivariate analyses determined significant associations (P Results Negative impression of the medical profession was independently associated with previous surgery that did not help symptoms (adjusted odds ratio [aOR] 1.77; 95% confidence interval [CI] 1.09–2.87; P = 0.021), presentation to an emergency room in the past 3 months (aOR 1.90; 95% CI 1.17–3.07; P = 0.009), and previous visits to a complementary health care provider (aOR 2.16; 95% CI 1.42–3.29; P  Conclusion Negative perception of the medical profession in women with endometriosis was associated with surgical treatment failure, emergency room use, and accessing complementary health care. Each identified factor offers an opportunity for intervention to improve the perception of the medical profession among women with endometriosis.

Endometriosis and Negative Perception of the Medical Profession

Drug-Induced Interstitial Lung Diseases.

A 71-year-old right-handed male nonsmoker with type 2 diabetes, hypertension, and chronic lymphocytic leukemia (CLL) never requiring active treatment presented to the hospital with 1 week of subacute-onset nausea, vomiting, and unsteady gait. On examination, he was afebrile with blood pressure 155/82 mm Hg and heart rate 62 bpm. He had right hemiataxia with wide-based gait. CT head and CT angiogram resulted in ischemic stroke diagnosis with no vascular abnormalities. Cardiac workup was unremarkable. He was managed with antiplatelet therapy and risk factor optimization.

https://n.neurology.org/content/neurology/96/24/1146.full.pdf

Nicole Ng

Papers

Medications to reduce emergence coughing after general anaesthesia with tracheal intubation: a systematic review and network meta-analysis.

Pharmacological methods for reducing coughing on emergence from elective surgery after general anesthesia with endotracheal intubation: protocol for a systematic review of common medications and network meta-analysis

Endometriosis and Negative Perception of the Medical Profession

Drug-Induced Interstitial Lung Diseases.

Clinical Reasoning: A 71-year-old Male with Horizontal Gaze Palsy, Anarthria, and Quadriparesis.