Intubation is a never-ending debate in chest medicine, but the COVID-19 pandemic has shifted the conversation. Familiar discussions over the timing of intubation, when to use bag-mask ventilation, and strategies to minimize aerosols have taken on new importance to clinicians, patients, and staff.

“There are attendant risks to mechanical ventilation, and there are very real consequences to delaying intubation in someone who is truly hypoxemic,” said June Chae, MD, Intensive Care Pulmonologist at the Mayo Clinic. “During the pandemic, this being a respiratory virus, there are consequences of letting someone linger too long on noninvasive strategies such as high-flow nasal cannulas and CPAP/BiPAP. Identifying the optimal time for intubation has been a moving target.”

Dr. Chae will co-chair a crossfire debate, Update in Airway Management During COVID-19, on Tuesday at 2:45 pm CT with Viren Kaul, MD, FCCP, Assistant Professor of Medicine at SUNY Upstate Medical University. The questions are not new, but the pandemic has brought reams of new data and clinical experience to the debate.

Intubation and mechanical ventilation bring well-documented risks of lung damage, pneumonia, over-sedation, and overmedication, as well as physical debilitation and deconditioning. But, multiple pre-pandemic studies demonstrated worsening mortality and morbidity with delaying intubation.

“Initially, we were intubating people quite early,” Dr. Chae said. “We saw people on ventilators for many more days than previously, and there were a lot of adverse outcomes. Then the pendulum swung the other way, and we were letting people linger too long before intubation, also with adverse outcomes. Ways we can better identify patients who are failing on noninvasive ventilation and the optimal timing for intubation is at the top of our conversations.”

Whether or not to use bag-valve-mask (BVM) post-induction is another familiar question that has taken on added clinical importance during the pandemic.

The 2018 Preventing Hypoxemia with Manual Ventilation During Endotracheal Intubation (PreVent) Trial showed that using BVM after induction can increase oxygenation, a key endpoint in airway management. At the same time, a BVM causes more aerosol generation from higher air flows across mucosal surfaces.

And, there is the familiar risk of introducing air into the esophagus and insufflating the stomach, which can lead to aspiration. Experience from working with patients with COVID-19 may help inform clinical practice.

The first pandemic respiratory virus in over a century has focused attention on ways to minimize the generation of aerosols across treatments and settings. And while personal protective equipment has become standard and required, aerosols remain a genuine cause of concern.

“CPAP, BiPAP, high-flow nasal cannulas, bag-valve masks, intubation practices—how do all these compare to something like a big cough?” Dr. Chae asked. “Yes, we have mitigation strategies with intubation boxes, drapes, and PPE, but none has been studied at the level of a randomized controlled trial. We’re still in the thick of the pandemic, still seeing more infectious and more transmissible strains such as Delta.”

And, there is ongoing concern about safety among physicians, nurses, respiratory therapists, and everyone else at the bedside, she said.

“Until we get more data, and there are ongoing trials, we need to fall back on proven strategies,” Dr. Chae said. “These are vital questions, both for providers who are under tremendous burdens and patients who are hypoxemic. Airway management is high stakes for both patients and care teams.”