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27 april 2020

COVID-19 and Risks Posed to Personnel During Endotracheal Intubation - JAMA

27-4-2020; 10.1001/jama.2020.6627
By: Weissman, et al.

Aim: Describe the hazards posed by aerosol-generating procedures for transmission of covid-19


  • Endotracheal intubation poses a risk of covid-19 for the proceduralist and should be performed as safe as possible.


  • +- 8% of COVID-19 patients require endotracheal intubation & mechanical ventilation
  • Aerosol generating procedures are: procedures performed on patients [that] are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing.
  • Especially intubation is hazardous:


    • Proceduralist is close to patients airway throughout entire procedure.
    • Proceduralist probably also present during associated aerosol generating procedures like bag ventilation
  • An SR and MA showed health care personnel exposed to aerosol-generating had a significantly increased odds ratio of 6.6 of COVID-19 infection.


    • absolute risk increase of 10-15% among intubators.
    • Tracheotomy, noninvasive ventilation and manual ventilation prior to intubation were also associated with increased risk.
  • Another study showed, after fluorizing patients respiratory secretions, after intubation health care workers had fluorescent signal on uncovered skin, hair and shoes (even though wearing: N95 respirators, eye protection, isolation gowns, and gloves)
  • Advice on protection during intubation:


    • avoiding elective intubations of patients with COVID-19
    • using intubation boxes as barriers to droplet spray, using antiviral filters between the face mask and the manual ventilation device, and performing procedures in airborne infection isolation rooms
    • only essential personnel present during the procedures, and cleaning and disinfection of the room after the procedure
  • Minimal PPE includes: gown, theatre hat, n95 mask, face shield and eye protection. Consider double gloves. Some advocate shoe covers and protective coverall
  • Hand-hygiene remains essential (before and after wearing PPE)
  • Any time skin or clothes become perceptibly contaminated with blood or body secretions during a procedure, the skin and hair should be cleaned with soap and water and clothes changed as soon as is feasible.