APSF Newsletter: Online-Only

Letter to the Editor: An Approach to Managing COVID-19 During Upper Endoscopy

April 6, 2020

Rene’ Miguel Gonzalez, M.D.

Endosocopy

Disclaimer: We aim to present letters from our readership that may generate further discussion on managing patients with COVID-19. Given the novelty of COVID-19, best-available clinical evidence is limited and supported from anecdotal reports from China, South Korea, Italy and other sites, and from studies of previous epidemics like SARS and MERS. The opinions expressed are those of the authors and not the APSF. These materials are presented for informational and educational purposes only and do not establish a standard of care or constitute medical or legal advice. The APSF does not support or endorse any specific idea, product, equipment, or trademarked technique. We strongly promote consistency with your governing bodies and organizations such as the CDC, WHO, ASA, AANA, and AAAA. Readers are reminded to consult with their institutions and medical/legal advisors regarding any of the views and opinions expressed by the authors.

In the midst of the new COVID-19 pandemic, anesthesia personnel find themselves on the front lines, facing and combating the spread of this airborne illness, often with sub-optimal personal protective equipment (PPE) due to shortages of N-95 masks and other protective respirators, gowns, gloves, and protective face shields.1

One of the areas where we most frequently encounter the risk of aerosolized airborne pathogens is in the endoscopy suite. Although more recent statistics are difficult to obtain, the number of upper GI endoscopies performed in the United States in 2009 was estimated to be an astounding 7.1 million.2 It should be noted that this figure did not include trans-esophageal echocardiographies [TEEs] or bronchoscopies. By comparison, there are currently only approximately 1 million total joint replacements performed annually in the U.S.3,4

Since upper endoscopy entails the insertion of a large foreign body, the endoscope, into the upper airway, gagging, retching, and coughing are common events. Obviously, if a nasal cannula is being used as the oxygen source, the patient’s nose and mouth are fully uncovered and exposed. As such, gagging and coughing may transmit a large load of airborne pathogens into the environment unimpeded.

Our group incorporated a commercially available O2 face mask, the Procedural Oxygen Mask (POM Medical, California, USA)5, into our high volume hospital-based endoscopy practice over one year ago. This O2 mask is inexpensive, single-use, and easy to use. Specifically designed and FDA-approved for upper endoscopies, it resembles a familiar traditional clear plastic O2 facemask, except that it provides self-sealing oral and nasal endoscopy ports which can accommodate almost any endoscope, as well as a capnography port and an included optional O2 reservoir side bag to provide an even higher FiO2. Since it is comfortable and lightweight, it can be left on the patient in the PACU. Other endoscopic O2 masks have been described,6,7 but this author has no personal experience nor knowledge of price, availability in the US, nor FDA approval of these other devices. In addition, many of the alternative devices appear to be used to provide positive pressure ventilation.

During the course of using the Procedural Oxygen Mask for several hundred upper endoscopies over the last 15 months, it was noticed, incidentally, that a beneficial “side effect” of the mask was that it may act as a mechanical barrier when patients cough during and after endoscopy. It appears that this unintended side benefit of endoscopy oxygen masks may be another compelling reason for its use in this environment.

Some have proposed performing all upper endoscopies under general anesthesia (GA) with a cuffed endotracheal tube (ETT). This technique is most indicated in those patients with full stomachs that present for emergencies. However, this may be an over-simplified, overly-optimistic solution, since intubation, and especially extubation, can produce even more coughing and aerosolization of viral particles. Additionally, endotracheal intubation and general anesthesia can be associated with other unintended and undesirable consequences (e.g., unanticipated difficult intubation, hemodynamic instability during TEE procedures or those patients with hypovolemia during an UGI endoscopy). In addition, administration of GA is ideally performed in a location with an anesthesia machine, which is unfortunately not available in several endoscopy suites. As the current moratorium on elective procedures is gradually lifted, it is reasonable to predict the backlog of “time sensitive” and eventually even elective upper endoscopic procedures will be performed in the future. As a result, MAC/ IV sedation may continue to be the anesthetic of choice for many upper endoscopies.

The decades of having upper endoscopy patients under MAC/IV sedation with just nasal cannula cough directly toward the faces of all of the healthcare workers present in the endoscopy suite and PACU must come to an end.

While it may not prevent all airborne particle transmission, the plastic face dome of endoscopic O2 facemasks provides some significant barrier to transmission of airborne pathogens from coughing during and after upper endoscopy. It may therefore function as a useful adjunct to the proper PPE. There is not yet a cure or vaccine for COVID 19.1 Again, we are faced with shortages of optimal PPE. Thus barrier transmission reduction is currently one of the few simple mitigation strategies available that may help to reduce risk to patients and healthcare workers during and after upper endoscopic procedures, including UGI’s, ERCP’s, bronchoscopies, TEE’s, and awake fiberoptic intubations. We must protect ourselves, our colleagues, and all of our patients.

 

Rene’ Miguel Gonzalez, M.D., is a Staff Anesthesiologist at Hackensack Meridian Southern Ocean Medical Center


Disclosure: The author has agreed to be an educational consultant for POM Medical


References

  1. https://www.asahq.org/in-the-spotlight/coronavirus-covid-19-information . Accessed March 28,2020
  2. Peery AF, Dellon ES, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology. 2012;143:1179-1187.
  3. Singh JA, et al. Rates of total joint replacement in the United States: future projections to 2020-2040 using the national inpatient sample. J Rheumatol April 2019.
  4. https://doi.org/10.3899/jrheum.170990. Accessed March 28, 2020
  5. https://www.pommedical.net. Accessed March 28,2020
  6. https://www.intersurgical.com. Accessed March 28,2020
  7. https://www.vbm-medical.com Accessed March 28,2020