Intubation and Ventilation Amid the COVID-19 Outbreak: Wuhan's Experience

Lingzhong Meng, M.D.; Haibo Qiu, M.D.; Li Wan, M.D.; Yuhang Ai, M.D.; Zhanggang Xue, M.D.; Qulian Guo, M.D.; Ranjit Deshpande, M.D.; Lina Zhang, M.D., Ph.D.; Jie Meng, M.D., Ph.D.; Chuanyao Tong, M.D.; Hong Liu, M.D.; Lize Xiong, M.D., Ph.D.

Disclosures

Anesthesiology. 2020;132(6):1317-1332. 

In This Article

Abstract and Introduction

Abstract

The COVID-19 outbreak has led to 80,409 diagnosed cases and 3,012 deaths in mainland China based on the data released on March 4, 2020. Approximately 3.2% of patients with COVID-19 required intubation and invasive ventilation at some point in the disease course. Providing best practices regarding intubation and ventilation for an overwhelming number of patients with COVID-19 amid an enhanced risk of cross-infection is a daunting undertaking. The authors presented the experience of caring for the critically ill patients with COVID-19 in Wuhan. It is extremely important to follow strict self-protection precautions. Timely, but not premature, intubation is crucial to counter a progressively enlarging oxygen debt despite high-flow oxygen therapy and bilevel positive airway pressure ventilation. Thorough preparation, satisfactory preoxygenation, modified rapid sequence induction, and rapid intubation using a video laryngoscope are widely used intubation strategies in Wuhan. Lung-protective ventilation, prone position ventilation, and adequate sedation and analgesia are essential components of ventilation management.

Introduction

The outbreak of the "Coronavirus Disease 2019" (COVID-19) started in December 2019 and quickly became a sweeping and unprecedented challenge to different stakeholders in mainland China.[1] Although the epidemic of COVID-19 is not yet over, it has already outpaced the previous severe acute respiratory syndrome (SARS) in 2003 and Middle East respiratory syndrome (MERS) in 2012 in nearly every respect, except for the mortality rate (Table 1). As of March 4, 2019, a total of 80,409 patients were diagnosed with COVID-19, and a total of 3,012 patients among those confirmed cases died, corresponding to a mortality rate of 3.7% (http://www.nhc.gov.cn/; accessed March 5, 2020). At the writing of this article on March 5, 2020, it appears that the momentum of the epidemic in mainland China, especially that in the epicenter of Wuhan, Hubei Province, China, has slowed down. However, the disease is gaining momentum outside of China, and it could ultimately become very severe (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen; accessed March 5, 2020). The concern is whether the COVID-19 epidemic could become a once-in-a-century pandemic.[2]

It did not take more than a few days before the healthcare system and providers in the epicenter of Wuhan were stunned by the COVID-19 outbreak's scale, speed, severity, and serious threat to healthcare providers themselves. Many patients developed serious symptoms, with some of them becoming critically ill.[1] The hospitals were quickly overwhelmed, forcing the administration to lock down the city of Wuhan, reactivate the workforce a few days ahead of the most popular holiday in China, Lunar New Year, reorganize the case flow, convert noninfectious floors and hospitals into infectious ones, build two new hospitals from ground zero, and open 16 Fang Cang hospitals using the big sport, conference, exhibition, and performance buildings (Figure 1; http://wjw.wuhan.gov.cn/; accessed March 1, 2020). The most common and severe complication in patients with COVID-19 is acute hypoxemic respiratory failure or acute respiratory distress syndrome (ARDS), requiring oxygen and ventilation therapies.[3] Some of these critically ill patients required intubation and invasive ventilation.[3,4] Moreover, although elective surgeries were largely cancelled, emergency surgeries for patients with confirmed or suspected COVID-19 were permitted to proceed. Some of these surgeries were performed under general anesthesia with endotracheal intubation. Intubating and ventilating patients with COVID-19 who are critically ill or require emergent surgical procedures present some unique challenges to providers.

Figure 1.

Dr. Junmei Xu is working at one of the sixteen Fang Cang hospitals in Wuhan amid the COVID-19 outbreak. Dr. Xu is a senior anesthesiologist and vice president of the Second Xiangya Hospital affiliated with Xiangya Medical School, Central South University, Changsha, Hunan, China. "Xiangya Second Hospital Xu Jun Mei" is written on his back. (Photograph by Dr. Junmei Xu.)

The healthcare system and providers need to be prepared in and outside of China for the COVID-19 outbreak now and for any outbreaks in the future. Preparedness is a pressing issue considering that many places and countries in the world are under-resourced, and at the time of writing this article, COVID-19 is quickly unfolding and evolving outside of mainland China. Healthcare providers, who are tasked with taking care of critically ill patients, need to perform the best practices of intubation and ventilation tailored explicitly to the victims of this sweeping COVID-19 outbreak and, at the same time, adhere to strict self-protection precautions. Wuhan's experience needs to be highlighted and quickly communicated throughout the world. In February 2020, we conducted four webinars specifically discussing the issues related to preparedness, airway management, lung-protective ventilation, the goal of oxygenation, and extracorporeal membrane oxygenation (Figure 2). We summarize the results of these discussions, which were based on firsthand experience with treating critically ill patients in Wuhan.

Figure 2.

Screenshot of the fourth webinar with live broadcast conducted on February 29, 2020. A total of 12 intensivists and anesthesiologists (10 people from China; 2 people from the United States) discussed the experience of using extracorporeal membrane oxygenation amid the COVID-19 outbreak. Nine of the 10 Chinese experts are currently working in Wuhan and taking care of critically ill patients with COVID-19. Most of these Chinese experts stay in hotels because they came from other provinces to Wuhan to share the workload that had overwhelmed the local teams. (Photograph by Dr. Lingzhong Meng.)

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