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BACKGROUND: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a novel respiratory infection responsible for a global pandemic with an associated high rate of critical illness and hypoxemic respiratory failure. Airway management is challenged by refractory hypoxemia and the risk of transmission. Standard techniques for rescue oxygenation and ventilation, and for preoxygenation may increase the risk of transmission to providers.
CASE REPORT: Two patients with COVID-19 and refractory hypoxemic respiratory failure, a 60-year-old woman with a history of hypertension and hypothyroidism with COVID-19 pneumonia, and a 72-year-old man with a history of hypertension with COVID-19 pneumonia and pneumothorax were oxygenated prior to intubation with an approach utilizing laryngeal mask airway, ventilator, and localized negative low generated by oropharyngeal suction catheters. This approach improved oxygenation, reduced desaturation, and theoretically reduced the risk of aerosols to the airway team. Both patients were subsequently intubated using video laryngoscopy with reduced peri-intubation desaturation.
CONCLUSIONS: Intubation of patients with COVID-19 and hypoxemic respiratory failure during pandemic conditions often occurs in circumstances with limited negative-pressure space and personal protective equipment. We report 2 cases in which an alternative approach to oxygenation reduced desaturation while potentially reducing the risk from aerosols to the airway team, and call for further clinical study and validation. This protocol has the potential to serve as a rescue technique in cases of failed intubation, which theoretically decreases the risks from aerosols for airway teams, and if validated will be translatable to other highly transmissible respiratory pathogens.

Keywords: airway management, COVID-19, Intubation, Respiratory Insufficiency