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  Table of Contents 
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 40-46

A questionnaire-based cross-sectional pilot survey on adherence to the recognized guidelines by the airway managers during intubation at the time of COVID-19 pandemic

1 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Anaesthesia and Critical Care, Command Hospital (SC), Pune, Maharashtra, India
3 Department of Neuroanaesthesiology, Bangur Institute of Neurosencies, IPGMER and SSKMH, Kolkata, West Bengal, India
4 Department of Anaesthesia and Critical Care, The Gujarat Cancer and Research Institute, BJMC, Ahmedabad, Gujarat, India

Date of Submission03-Sep-2020
Date of Acceptance22-Dec-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (SC) Pune - 411 040, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_142_20

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Background and Aims: COVID-19 infection has the potential to spread exponentially during aerosol-generating procedures like intubation. The aim was to find the compliance toward the actual practice as well as the existing knowledge gap and adherence to the guidelines among the medical professionals while attempting intubation in a known or suspected COVID-19 patients.
Materials and Methods: A cross-sectional web-based survey format was planned using English questionnaire in an online form (Google® Forms). One hundred and forty valid responses for 27 questions were received. Maximum participation was received from Indian anesthesiologists working in government, semi-government, and private health facilities, performing the intubation routinely. All the valid responses were statistically analyzed by calculating the significant difference in means and proportions, with P < 0.05 being considered statistically significant.
Results: Eighty percent of the respondents received training for donning and doffing and regularly wore personal protective equipment for the airway procedure. Scarce simulation training (22.1%), minimum screening before entering into a intubation scene (37.9%), frequent use of bag-mask ventilation (18.2%) or high flow nasal cannula (19.7%) use for preoxygenation, confirmation of the depth of endotracheal tube by auscultation (34.5%), and having no plan B in case of unanticipated difficult airway (27.9%) make the knowledge gap evident. The survey pointed out toward the infrastructural requirement of negative pressure intubation rooms, availability of waveform capnography, and widespread use of videolaryngoscope.
Conclusion: This survey gives us an insight into the compliance with existing lacunae and nonuniform practices of the recommended guidelines for the airway management during COVID-19 pandemic with its pragmatic solution.

Keywords: Airway management, coronavirus, COVID-19 pandemic, endotracheal intubation, infection transmission, personal protective equipment, severe acute respiratory syndrome coronavirus 2

How to cite this article:
Guha D, Dwivedi D, Paul D, Chakrabarti S, Talukdar J, Singh S. A questionnaire-based cross-sectional pilot survey on adherence to the recognized guidelines by the airway managers during intubation at the time of COVID-19 pandemic. Indian Anaesth Forum 2021;22:40-6

How to cite this URL:
Guha D, Dwivedi D, Paul D, Chakrabarti S, Talukdar J, Singh S. A questionnaire-based cross-sectional pilot survey on adherence to the recognized guidelines by the airway managers during intubation at the time of COVID-19 pandemic. Indian Anaesth Forum [serial online] 2021 [cited 2021 May 9];22:40-6. Available from: http://www.theiaforum.org/text.asp?2021/22/1/40/309825

  Introduction Top

The world is experiencing an unprecedented time in the year 2020. The year started with news of large cluster of pneumonia cases with unknown etiology in the city of Wuhan in Hubei province of China. The causative organism was later named severe acute respiratory syndrome coronavirus 2 and the disease was named COVID-19. The first case in Wuhan city was detected on December 31, 2019, and since then, in July 2020, the total number of confirmed cases in the world is nearly 14 million and total number of deaths nearing 600,000. In India, the total number of confirmed COVID cases is little over 1 million and the total number of confirmed corona deaths has crossed 25,000 mark.

Common presentation with this disease includes fever, cough, respiratory distress, diarrhea, fatigue, and sudden loss of taste. Pneumonia, acute severe respiratory distress syndrome, and renal insufficiency are among the most severe complications.[1] Critically ill COVID-19 patients frequently need noninvasive ventilation and may require intubation and mechanical ventilation in the intensive care unit (ICU) and as well as during the emergency surgeries. Thus, during COVID-19 epidemic, intubation of these patients/suspects can be considered a fairly common procedure.

With the exponential spread of this pandemic across the globe, all the leading national and international medical societies and local governments have published set of guidelines for the management of COVID-19 patients which include general care, management protocols for the patients, and the advisories for the aerosol-generating procedures like endotracheal intubation (ETI).[2],[3],[4],[5],[6],[7] Inception of the various guidelines by the leading health agencies whether being followed in principle needs to be ascertained as different countries have difference in health infrastructure, manpower distribution, and expertise among the health-care workers (HCWs). The ideal guidelines derived by leading health committees are sometimes difficult to follow because of huge patient load, institutional policy or scarcity of raw materials such as personal protective equipment (PPE), or ignorance of the HCWs. Therefore, the primary objective of the survey was to find out the actual practice as well as the knowledge and adherence to the guidelines related to ETI among the medical professionals while attempting intubation in a known or suspected COVID-19 patients in the emergency department, ICU, isolation wards, or in operation theater (OT) for the emergency surgeries in their day-to-day practice.

  Materials and Methods Top

Maintaining the regulations of social distancing, this survey was conducted in a cross-sectional web-based format using English questionnaire in an online form (Google® Forms) and it was distributed using online modes of communications such as Facebook®, WhatsApp®, and Telegram®. Respondents aimed were doctors involved with anesthesiology and critical care and involved with the emergency medicine specialty in India. We also shared it with few international anesthesiology groups via WhatsApp® and Telegram®. The participants filled the form individually in estimated time of 5–7 min. The response was noted along with the compulsory E-mail addresses of the respondents to confirm the identity. The survey form also carried consent by the respondents to use these data for scientific research purposes. The time period of the study was from May 25, 2020, to July 01, 2020. As the data contain only information about the professional methods carried out by individuals under their own consent, no ethical approval was taken for this survey.

The final questionnaire contained total 27 questions divided in two sections. Access the Google Forms at (https://docs.google.com/forms/d/e/1FAIpQLSduHaacipNqD32EB98 ULv9-wHijRzVG2-rPc-3WAqbBMBPIOg/viewform? usp=sf_link). The first section was designed as “Personal Details” which included sociodemographic and professional data (name, age, country, specialty, department, and experience). The next section was all about the procedure. It contained 21 questions with multiple choices (tick boxes in few questions for more than one response).

All the valid responses were statistically analyzed by calculating the significant difference in means and proportions, with P < 0.05 being considered statistically significant. Level of significance was measured to evaluate shift of the actual practice from ideal guidelines.

  Results Top

We received 140 valid responses using snowball sampling technique during the study period from the specialists working in government, semi-government, and private health facilities.

The characteristics of the study group with demographic variables are presented in [Table 1]. The mean age of the respondents, who participated in the survey was 35.49 years. The responses received in majority were from India, though two respondents participated from the UAE and Tanzania, one response each was received from Germany, the UK, Peru, Pakistan, Egypt, and Algeria. Majority (129) of the respondents were from the broad specialty anesthesia and its subspecialties, whereas 11 respondents were from other specialties. These respondents had varied experiences in the field of specialization, and most of the respondents were routinely performing the intubation in OT, ICU, or emergency room.
Table 1: Characteristics of the study group

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The questions about the intubation preparation and procedure generating the ordinal response are presented in [Table 2], which include details about donning and doffing of PPE, status of the simulation training for intubation, view about whether, intubation has become difficult following the COVID-19 guidelines, status about the screening of the HCWs, and about the choice of person performing the intubation. Eighty-four respondents (60.4%) strictly wore PPE before intubation even during emergency situation, whereas 41 respondents (29.5%) said they wore PPE in most of the cases. Fourteen respondents (10.1%) said to have used PPE very rarely before emergency intubation and the reason was said to be time constraint during emergency situation and the unavailability of PPE. On enquiring about the type of air conditioning (AC), it was reported that in majority, the intubation was performed in a centralized AC rooms (49.6% or 69 responses), 46 respondents (33.1%) had rooms with separate dedicated AC, 10.1% rooms (14 responses) were non-AC, and only 10 (7.2%) respondents had done intubation in a negative pressure room.
Table 2: Questions with ordinal responses

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Among the difficulties encountered during intubation, fogging of the goggles was faced by the majority (114 responses). Two other major problems were restrictions of hand movements (81 responses) and difficulty in patient positioning (44 responses). Response to extra protective layers used during intubation is described in [Figure 1]. One hundred and two respondents (72.9%) said to have two to five HCWs in the intubation room during intubation, 23 responses (16.4%) suggest solo operator, and 10% of the responses suggest no specific restriction on number of people attending intubation. All physicians have used pulse oximetry for measuring oxygen saturation before intubation. Electrocardiography (ECG) and blood pressure (BP) monitoring were in place in 85% and 84.3% of the cases, respectively, but only 46.4% of the respondents (65 responses) had waveform capnography and 17.1% had temperature monitoring before intubation.
Figure 1: Response to extra protective layers used during intubation

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One hundred and five respondents (75%) followed rapid sequence intubation (RSI) technique, 26 respondents (18.6%) followed standard method of intubation using neuromuscular blockers, and 9 responses suggested intubation under sedation without muscle relaxant. [Figure 2] describes the methods of preoxygenation adopted by the respondents.

Response to the use of the videolaryngoscope during intubation is illustrated in [Figure 3]. Most common modified Cormack–Lehane (CL) view observed was IIa in 39 cases (30.2%), IIb in 73 cases (56.6%), and III in 10.9% of cases. Endotracheal tube (ETT) position was confirmed by monitoring bilateral chest expansion by 48 respondents (34.5%) and monitoring ventilator waveforms by 46 respondents (33.1%). Auscultation of the chest was also practiced by 39 respondents (28.1%), whereas 6 people confirmed position by chest X-ray or ultrasound.
Figure 2: Methods of preoxygenation employed

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Figure 3: Use of videolaryngoscope during intubation

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Complications during intubation have been presented in descending order, with desaturation (79.9%) being the most common followed by trauma during laryngoscopy (26.9%), severe hypoxia (21.6%), exaggerated stress response (6%), arrythmias (3.7%), and esophageal intubation (0.7%) being the least common. During unanticipated difficult airway scenario, supraglottic airway was plan B for 83 respondents (59.3%) followed by 7.1% and 5.7% of the respondents who desired tracheostomy and fiber-optic intubation, respectively, but 27.9% of the respondents did not have any protocol in place and preferred few more attempts with adequate bag-mask ventilation [Figure 4].
Figure 4: Protocol followed during unanticipated difficult airway

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Sterilization following the use of the airway equipment, the majority (55.8%) preferred 1% hypochlorite solution, 21.7% of the respondents cleaned it with alcohol-based hand sterilizer, and 9.4% people used running water.

  Discussion Top

Intubations during COVID pandemic are thwart with challenges which include both clinical and mechanical.[2] Complicated clinical scenario in severely ill COVID patients (“Happy Hypoxia”) or suspects will require prompt intubation if their condition deteriorates;[8] on the other hand, the protective measures advised for intubation during pandemic create another level of challenge. Among all the aerosol-generating procedures, intubation is most risky because the airway operator remains in close contact with the patient for prolonged duration and needs to carry out other ancillary aerosol-generating procedure such as suctioning.[3] With high rate of community transmission and the huge number of asymptomatic cases, all intubations should be considered as a potential risk and all due precautions are needed to be taken as per established COVID-19 guidelines.[4],[6]

The primary step a HCW can follow is to protect themselves and wear full PPE at all times during intubation[4],[6] after being trained in donning and doffing of PPE.[5],[6],[7] The survey shows that the lacuna exists in the training since a significant number of respondents (19.3%) did not receive any formal training. The other important step is the environment control which requires emphasis to protect cross infection among HCWs, and this can be dealt by the inclusion of the negative pressure room for intubation, minimum attendance during intubation, and a proper screening of HCWs to restrict entry of vulnerable people.[4],[5],[6],[9],[10] This survey points out that many health-care facilities significantly deviated from the protocol laid out by the Indian Society of Anaesthesiologists (ISA), All India Difficult Airway Association (AIDAA), and Difficult Airway Society (DAS) guidelines.[4],[5],[6] Only 7.2% of the respondents had access to a negative pressure room and majority of the procedural rooms were centralized air conditioned. ISA strongly recommends to keep the central air conditioner switched off. Laminar air flow and use of air purifier with high efficiency particulate air filters are preferable.[5],[6],[11] Yao et al. and AIDAA guidelines suggested two operators for all intubations.[5],[7] The minimum attendance to reduce the footfall in the intubation room has also been suggested by ISA advisory, Chahar et al., and Orser Beverley.[6],[9],[10] In our survey, we found that in majority of the cases, the count was between two to five and solo operator in only 16.4% of the cases. Thus, it is evident that in many centers the intubation scene is overcrowded. Similarly, screening of vulnerable individuals depending on their age, co-morbidities, immune status, pregnancy status is not being done in most of the centers (62.1%). Whereas screening and limiting the number of individuals entering intubation room needs nothing but awareness from the part of administration and team leader.

The intubation room should be well equipped with minimum standards of monitoring which includes, noninvasive blood pressure (NIBP), waveform capnography, pulse oximetry and ECG.[4],[5] All respondents have used pulse oximetry (100%); 84% of the respondents used ECG and NIBP monitoring whereas, waveform capnography monitoring was used significantly in lesser proportion (47.5%). The inference drawn is the nonuniform practice of minimum standard of monitoring as being laid down by WHO and ISA.[12]

Majority of the airway operators agreed that the intubation procedure has become difficult while maintaining all the layers of protection. The most common difficulty faced was fogging of the goggle (81.4%). The finding was in accordance with the other studies.[2],[4],[7] It has been said that making a layer of liquid soap[4],[7] or transparent hand sanitizer[2] over the inner side of the goggle may minimize fogging. Other two most common problems reported are dexterity with restricted hand movements inside the intubation box and patient positioning. The same concerns were also discussed by Kearsley.[13] Donning PPE increases difficulty and discomfort for the airway manager, but strict compliance should be followed and the survey found 89.9% airway operators were wearing PPE before intubation as per the laid down guidelines. Reason for not wearing PPE was the time constraint during emergency intubation and 13% people also said they had to face unavailability of PPE on various occasions. Some protective covering on the patient is always mandated along with PPE during a highly aerosol-generating procedure like intubation. Taiwan transparent intubation box[14] has been the most preferred adjunct for intubation used by 43.3% of the respondents. Canelli et al. suggested the use of the “Aerosol box” in augmenting additional protection.[15] Among the other modes of protection 35.2% of the respondents used transparent plastic, few respondents used wet gauge,[6] disposable sheets, surgical mask etc., Despite all these the best way to reduce aerosol generation during intubation is a fast and accurate intubation for which most of the guidelines suggest handling the airway by the senior most experienced airway operator[2],[3],[4],[5],[6],[7],[9],[10] which was being followed in 60.4% of the cases. This can circumvent multiple attempts, aerosol generation, and chance of increased complications during intubation. Donning of PPE, with extra protective layers such as face shield and modified airway techniques, needs regular full in situ simulation practice for every HCW to make the actual procedure smooth and hassle free.[4],[6],[5] However, this survey suggests that 77.9% of the respondents did not receive any such simulation practice perhaps due to unavailability of the simulation laboratories.

Yao et al.'s case series described most of the intubations under RSI technique using rocuronium with minimum bag-mask ventilation and intubation using videolaryngoscope.[7] DAS, ISA, and AIDAA guidelines also advocate the same, though DAS guideline prohibits the use of any new technique in which the airway operator is not trained.[4] In this survey, most of the respondents were found to be following the protocol of RSI intubation using succinylcholine and preoxygenation using tight mask holding with high flow oxygen through a breathing circuit, though a good proportion of respondents used high flow nasal oxygen and bag-mask ventilation for preoxygenation which are both contraindicated as per various guidelines in view of higher risk of aerosol generation.[2],[3],[4],[5],[6],[7] The use of videolaryngoscopy was found to be very low among the respondents where only 14.3% of the airway operators had routinely used it and 52.9% of the respondents did not have any access to videolaryngoscope. This was in contrast to the case series by Yao et al. where in 89.6% of the cases, videolaryngoscope was used.[7] In India, access to videolaryngoscope is limited for most of the airway operators; moreover, videolaryngoscope has a steeper learning curve. Therefore, one can inference that direct laryngoscopy by conventional laryngoscope is not contraindicated, but the videolaryngoscopy is preferred as one should do laryngoscopy in the shortest possible time by the method in which one has attained the expertise. CL views observed in majority (56.6%) were restricted (CL grade IIb), indicating toward difficult glottic view with the use of the aerosol box, increased interfaces between the operator and the patient, and the attempted direct laryngoscopy in these patients.

Complications reported are frequent during intubation in COVID-19 patients or suspects where hemodynamic instability coincides with hypoxia. Physicians witnessed desaturation (79.9%), severe hypoxia (21%), and severe hypotension (12%) in this survey, which appeared quite similar to the findings by Yao et al.[7] Trauma during laryngoscopy (26.9%) was exclusive to this study which was not observed by other studies, and this could be attributed to the emergency intubations in crashing patients, modified surroundings, familiar techniques with increased interfaces, and lesser use of videolaryngoscopy. ETT position confirmation in this survey conformed with the guidelines[4],[5] which suggested, to observe the bilateral chest rise with waveform capnography, use of early lung ultrasound and chest X-ray, but 28.1% of the respondents have still used auscultation which is avoidable. When asked about the airway management plan during the unanticipated difficult airway of a COVID patient, 59.3% answered correctly and suggested using supraglottic device as their rescue plan which was in accordance with the guidelines.[4],[5],[6] Fiber-optic procedure which is deemed highly aerosol generating[4],[6],[10] was also being suggested by 27.9% of the respondents and others planned to give few more attempts with bag-mask ventilation which indicates clearly the lack of predefined Plan B.

The last but equally important step is sterilization of airway equipment, about which we found most of the respondents (55.8%) followed the standard practice of cleaning the airway instruments with 1% hypochlorite solution,[5] but a large number of respondents were also following some nonstandardized technique such as cleaning with alcohol-based sanitizer or cleaning under running water.

Survey has a limitation of following trends over a limited period of time. The data collected at a specified time during survey, cannot measure the magnitude of change happening over a desired period. In our case, it is applicable to the constantly changing knowledge and the practices of the specialist as per the updated latest guidelines on the subject.

  Conclusion Top

This limited survey gives us an insight into the existing lacunae and nonuniform practices of the recommended guidelines for a successful airway management during the COVID-19 pandemic. The outcome could be improved adhering to the evidence-based guidelines formulated by the various national and international bodies as well as with the incorporation of the simulation-based practice of the techniques.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ministry of Health & Family Welfare, Directorate General of Health Services (EMR Division), Government of India. Version 5; July 03, 2020. Updated clinical management protocol for COVID-19. Retrieved from: http://www.mohfw.gov.in. [Last accessed on 2020 Sep 01].  Back to cited text no. 1
Luo M, Cao S, Wei L, Tang R, Hong S, Liu R, et al. Precautions for intubating patients with COVID-19. Anesthesiology 2020;132:1616-8.  Back to cited text no. 2
Weissman DN, de Perio MA, Radonovich LJ Jr. COVID-19 and risks posed to personnel during endotracheal intubation. JAMA 2020;323:E1-2.  Back to cited text no. 3
Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. 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. Anaesthesia 2020;75:785-99.  Back to cited text no. 4
Patwa A, Shah A, Garg R, Divatia JV, Kundra P, Doctor JR, et al. All India difficult airway association (AIDAA) consensus guidelines for airway management in the operating room during the COVID19 pandemic. Indian J Anaesth 2020;64:S107-15.  Back to cited text no. 5
Malhotra N, Joshi M, Datta R, Bajwa SJS, Mehdiratta L. Indian Society of Anaesthesiologists (ISA National) advisory and position statement regarding COVID-19. Indian J Anaesth 2020;64:259-63.  Back to cited text no. 6
  [Full text]  
Yao W, Wang T, Jiang B, Gao F, Wang L, Zheng H, et al. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: Lessons learnt and international expert recommendations. Br J Anaesth 2020;125:e28-37.  Back to cited text no. 7
Couzin-Frankel J. The mystery of the pandemic's 'happy hypoxia'. Science 2020;368:455-6.  Back to cited text no. 8
Orser Beverley A. Recommendations for endotracheal intubation of COVID-19 patients. Anesth Analg 2020;130:1109-10.  Back to cited text no. 9
Chahar P, Dugar S, Marciniak D. Airway management considerations in patients with COVID 19. Cleveland Clinic Journal of Medicine. 2020. DOI: https://doi.org/10.3949/ccjm.87a.ccc033.  Back to cited text no. 10
Zhao B, Liu Y, Chen C. Air purifiers: A supplementary measure to remove airborne SARS-CoV-2. Build Environ 2020;177:106918.  Back to cited text no. 11
Divatia JV. Safe anaesthesia for all Indians: A distant dream? Indian J Anaesth 2017;61:531-3.  Back to cited text no. 12
[PUBMED]  [Full text]  
Kearsley R. Intubation boxes for managing the airway in patients with COVID-19. Anaesthesia 2020;75:969-77.  Back to cited text no. 13
Tseng JY, Lai HY. Protecting against COVID-19 aerosol infection during intubation. J Chin Med Assoc 2020;83:582.  Back to cited text no. 14
Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier enclosure during endotracheal intubation. N Engl J Med 2020;382:1957-8.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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