Use of positive pressure ventilation during tracheal intubation before and during the COVID-19 pandemic

Rationale: Positive pressure ventilation (PPV) during tracheal intubation of critically ill adults reduces the risk of peri-procedural hypoxemia. Patients with COVID-19 are at increased risk of hypoxemia during tracheal intubation, but expert guidelines have recommended against the use of PPV for patients with suspected or known COVID-19 based on a concern that PPV may increase aerosolization and the risk of infection of healthcare providers. Evidence informing the impact of these recommendations on the airway management practices for patients with COVID-19 is currently limited. Methods: We conducted a survey of perceived intubation practices in 21 emergency departments (EDs) and intensive care units (ICUs) participating in either of two randomized trials (clinicaltrials.gov identifiers: NCT03928925 and NCT03787732) within the Pragmatic Critical Care Research Group between 9-3-2020 and 10-21-2020. At each site, the site investigator provided information on perceived airway management practices among patients intubated prior to the COVID-19 pandemic and during the pandemic. The primary outcome for this analysis was the use of any PPV, either bag-mask ventilation (BMV) or non-invasive ventilation (NIV), between induction and laryngoscopy. Results: We received responses from 19 of 21 sites (90%). Use of BMV was reported in a median of 35% of intubations [IQR: 0-67%] prior to the pandemic compared with a median of 0% of intubations [IQR: 0-20%] performed among patients with known or suspected COVID-19 (p=0.004). Investigators reported using NIV in a median of 10% of intubations [IQR: 0-25%] prior to the pandemic, compared to 10% [IQR 0-30%] of intubations among patients with known or suspected COVID-19 (p=0.20). Receipt of any positive pressure was reported in 50% [IQR: 0-85%] of intubations prior to the pandemic, compared to 30% [IQR: 0-55%] of intubations among patients with known or suspected COVID-19 (p=0.06) (Figure 1). Conclusions: Based on reported practices at 19 EDs and ICUs participating in either of two ongoing clinical trials, we found that the perceived use of BMV between induction and laryngoscopy decreased in patients with known or suspected COVID-19 while the perceived use of NIV did not change. Despite recommendations to avoid its use, perceived use of PPV remains common among patients with suspected or known COVID-19. This reflects the tension between balancing risk to providers and patients for a condition that places both groups at high risk of peri-procedural complications.