In response to COVID-19 I have two main questions Intubation: With intubation should we be switching to airborne precautions for PPE? NSAIDs: I have read multiple reports from credible sources about withholding NSAIDs from COVID-19 patients. Will this be something coming down the pipe for people who screen positive? Nasal Intubation: Due to removal of CPAP (one of the main reasons nasal intubations became rare) will be seeing nasal intubation reintroduced to services that just removed it as another alternative as we dont know truly when we will be returning to practice as normal?
Airborne precautions should be used with any procedure or treatment where aerosilization can occur. This includes intubation, SGA insertion, BVM and high flow oxygen administration.
The quick answer: No, we will continue to use NSAIDs.
The NSAID question is one that was raised out of theoretical risk, not proven risk. The issue has been brought up on social media, notably with the French Health Minister, Olivier Veran tweeting, taking inflammatory drugs (ibuprofen, cortisone€¦) could be an aggravating factor of the [COVID-19] infection. NSAIDs if taken for long periods of time (this duration is unknown) MAY cause upregulation of the angiotensin-converting enzyme 2 (ACE2). The COVID-19 virus bind to their target cells in the lungs through ACE2. Therefore, it was theorized that people who take NSAIDs for prolonged periods of time MAY have increased duration of the virus, as they may have more opportunity to bind. This was extrapolated based on a letter in the Lancet journal, Mar 11, 2020. Within this letter it was suggested that antihypertensive medications ACE inhibitors and ARBs may upregulate ACE2 and therefore may facilitate worse infection.
Notably, this theoretical risk for both NSAIDs and the antihypertensive medications has been assessed and dispelled by many national bodies. Health Canada recently stated there is no scientific evidence that ibuprofen worsens COVID-19 symptoms and along with many national bodies including the Canadian Cardiovascular Society, stress that it is important for patients taking medication for chronic disease, not to stop their treatment.
Canadian Cardiovascular Society. Guidance from the CCS COVID-19 rapid response team. Published online Mar 20, 2020.
Fang L, Karakiulakis G, Roth, M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med 2020. Published Online March 11, 2020.
Health Canada. No scientific evidence that ibuprofen worsens COVID-19 symptoms. Information update. Published online Mar 20, 2020.
With the removal of CPAP, we suggest Supraglottic Airway as the best option in airway management (as long as they meet the PCP Condition of Patient must be in Cardiac Arrest, or ACP Condition of Absent gag reflex). The SGA will allow for a closed-system and less chance of aerosolization. Nasal Intubation would be a high risk procedure for transmission of virus.