Novel technique for safe fibreoptic tracheal intubation in COVID-19 patients

To the editor,

The 2019 novel coronavirus disease (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents significant challenges to anaesthesiologists. COVID-19 can be transmitted to clinicians involved in patient care, particularly during aerosol-generating procedures [1], [2], such as fibreoptic intubation. The fibreoptic intubation, therefore, needs to be adapted in order to prevent the spread of SARS-CoV-2. In this article, we present a novel technique designed to improve safety during fibreoptic intubation; the technique uses disposable clear drapes that are generally accessible in any operating theatre or institution.

In this step-by-step demonstration of the adapted fibreoptic intubation technique (see supplementary video), we use a manikin to represent the patient. The patient is placed in the supine position on the operating table and draped with a surgical microscope drape (Zeiss® MD® Microscope Drape, 65 mm lens cover). The microscope drape is a clear plastic material that includes an annular housing, which is normally designed to fit around the objective lens portion of the microscope. In this adapted technique, the annular housing is positioned around the mouth and nose of the patient.

An ultrasound (US) probe cover (Vygon, Ecouen, France) is adjusted to the annular housing by its open end and securely fastened using tape. The other extremity of the US probe cover is opened by making a 4 to 5-cm incision through which the fibrescope is introduced with an ensleeved endotracheal tube (ETT). A second piece of tape is provided to securely fasten the cover to the cabling in order to ensure easier and safe handling during the procedure.

The microscope drape further includes several sleeve cuffs, which normally serve as eyepiece covers for the surgical microscope. Forearms of an assistant can be inserted through two small cuts in the sleeve cuffs to keep a tight fit. The assistant will proceed with hands underneath the drape, allowing him to stabilise the scope with the hand over the nose or mouth if needed, advance the ETT into the trachea over the scope shaft, inflate the ETT cuff, and secure the ETT with a clamp just after fibreoptic shaft withdrawal. The fibrescope with its cover are then securely removed in one-step; the tracheal tube is connected to the breathing circuit and the clamp is subsequently removed.

To ensure procedural fluency of the technique, we conducted a test run with a presumed COVID-19 patient. The drapes were prepared in advance in order to avoid wasting time. A skilled anaesthetist performed a successful nasal fibreoptic intubation under deep general anaesthesia using a neuromuscular blocking agent. A surgical mask was placed over the mouth of the patient for additional security. The procedure was smooth and the operators reported a high degree of satisfaction with the technique.

In summary, this technique, which uses accessible operating theatre supplies, can be a useful adjunct in minimising viral contamination by respiratory secretions during outbreaks of highly infectious diseases, such as COVID-19.

Research support

Support was provided solely from institutional and/or departmental sources.

Disclosure of interest

The authors declare that they have no competing interest.