Andrawes, S

Benias, PC

Bernstein, DE

Haddad, F

Hogan, DE

Inamdar, S

Sejpal, D V

Trindade, A J

Wander, P

English

Hofstra Northwell Academic Works (Hofstra Northwell School of Medicine)

Journal Articles 2020 Elective endotracheal intubation for urgent gastrointestinal endoscopy among hospitalized patients with SARS-CoV-2 P Wander Northwell Health DE Hogan Northwell Health S Inamdar PC Benias Zucker School of Medicine at Hofstra/Northwell F Haddad Northwell Health See next page for additional authors Follow this and additional works at: https://academicworks.medicine.hofstra.edu/publications  Part of the Gastroenterology Commons Recommended Citation Wander P, Hogan D, Inamdar S, Benias P, Haddad F, Andrawes S, Bernstein D, Sejpal DV, Trindade AJ. Elective endotracheal intubation for urgent gastrointestinal endoscopy among hospitalized patients with SARS-CoV-2. . 2020 Jan 01; ():Article 6456 [ p.]. Available from: https://academicworks.medicine.hofstra.edu/publications/6456. Free full text article. This Article is brought to you for free and open access by Donald and Barbara Zucker School of Medicine Academic Works. It has been accepted for inclusion in Journal Articles by an authorized administrator of Donald and Barbara Zucker School of Medicine Academic Works. For more information, please contact academicworks@hofstra.edu. Authors P Wander, DE Hogan, S Inamdar, PC Benias, F Haddad, S Andrawes, DE Bernstein, D V. Sejpal, and A J. Trindade This article is available at Donald and Barbara Zucker School of Medicine Academic Works: https://academicworks.medicine.hofstra.edu/publications/6456   Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website.  Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.  LETTER TO THE EDITORElective endotracheal intubation forurgent gastrointestinal endoscopyamong hospitalized patients withSARS-CoV-2To the Editor:The most devastating consequence of the novel corona-virus disease (COVID-19) is respiratory failure. Mechanicalventilation with endotracheal (ET) intubation in this settingis associated with a poor prognosis.1 Still, many patientsrequire urgent procedures during hospitalization forCOVID-19 necessitating anesthesia and ET intubation.However, whether extubation is readily feasible among pa-tients hospitalized with COVID-19 with potential pulmo-nary involvement is unknown. The primary aim of thisstudy was to determine the feasibility of extubation afterelective intubation for GI endoscopy among patients hos-pitalized with COVID-19.We present a case series of prospectively collectedendoscopy data from April 1, 2020, to May 12, 2020,from 4 tertiary care hospitals within the Northwell HealthSystem in New York. Consecutive hospitalized patientswere included if (1) patient’s age was >18 years, (2) patientwas confirmed positive for COVID-19, and (3) urgent GIendoscopy was required. Only emergent or urgent caseswere performed during this time according to GI societyguidelines.2,3 This study was approved by the ZuckerSchool of Medicine/Northwell Health System InstitutionalReview Board.Patients were considered positive for COVID-19 if theirtest results were positive for severe acute respiratory syn-drome coronavirus 2 (SARS-CoV-2) infection by polymer-ase chain reaction testing of nasopharyngeal sampleswithin 2 days of the procedure. Administration of supple-mental oxygenation in COVID-19 patients was standardizedthroughout Northwell in a protocol. If the oxygen satura-tion was below 94% on room air, nasal cannula oxygenwas given. If the oxygen saturation was below 94% onmaximum nasal cannula support, a nonrebreather maskwas used. If the patient was desaturating and in respiratorydistress with the nonrebreather and in the prone position,an ET tube was placed.The anesthesia type was at the discretion of the anesthe-siologist and based on standard of care for each hospital. Thedecision for ET intubation was based on the ability to protectthe airway against aspiration once the patient was sedated.However, in general, patients with hematemesis, vomiting,or GI lumen obstruction and those undergoing ERCP (giventhe patient was placed prone) had ET intubation. The datawere analyzed by type of anesthesia: (1) elective ET intuba-tion just before the endoscopy, (2) ET intubation for respira-tory failure during the hospitalization, or (3) sedation withmonitored anesthesia care. The main outcome was therate of extubation just after the procedure in the electiveET intubation group.The SAS statistical software version 9.4 (SAS Institute,Cary, NC, USA) was used to conduct all statistical tests.The c2 test or Fisher exact test was used to compare cate-goric data, and the Student t test was used to comparecontinuous data. A P value of < .05 was considered statis-tically significant.A total of 111 patients with COVID-19 were included in thestudy period during the COVID-19 pandemic. Table 1 lists thepatient and procedure characteristics between the groups.Patient age, gender, body mass index, comorbidities, andindications were similar between groups.Forty-five patients (45/111, 41%) underwent elective ETintubation. All patients but 1 were receiving oxygen by nasalcannula (98%, 44/45). One patient required a 100% nonre-breather mask. Thirty-eight percent of the patients (17/45)had chest radiograph findings indicating pulmonary involve-ment of COVID-19. Of the 45 patients, 98% (44/45) were ex-tubated safely after the procedure. One patient hadprolonged ET placement but was able to be extubated after3 days. This patient was receiving nasal cannula oxygenbefore the procedure. All patients remained extubated afterthe procedure without respiratory adverse events (patients’charts abstracted until 72 hours after the procedure).Twenty-nine (29/111, 26%) patients had an ET already inplace for respiratory failure before endoscopy. Nine patientswere extubated and remain ET tube free, 5 patients died inthis group of COVID-related causes, 5 remain with an ETtube, and 10 underwent tracheostomy. Thirty-seven (37/111, 33%) underwent sedation with monitored anesthesiacare safely without respiratory adverse events. Forty-ninepercent of the patients (18/37) had chest radiograph findingsindicating pulmonary involvement of COVID-19. None ofthese patients required ET intubation during the procedure.Our study has limitations. These data are applicable onlyto tertiary care centers. In addition, there was a lack ofstandardization of who received elective general anesthesiaversus sedation among the 4 hospitals because that choicewas based on the discretion of the anesthesiologist andstandard of care at each hospital. However, this was mainlybased on the ability to protect the airway against aspira-tion, and thus per standard practice, in most institutions.In conclusion, endoscopy can be a lifesaving procedurefor indications that are urgent or emergent in patients withCOVID-19. Often these procedures require ET intubation,of which the pulmonary risk was previously unknown inthis cohort. This series shows that elective ET placementin patients with COVID-19 appears to be well toleratedand removable shortly after the procedure for the majoritywww.giejournal.org Volume -, No. - : 2020 GASTROINTESTINAL ENDOSCOPY 1of patients who require nasal cannula oxygen supplemen-tation before the GI endoscopy procedure.DISCLOSUREDr Benias is a consultant for Olympus America, ApolloOverstitch, Boston Scientific, and FujiFilm. Dr Andrews isa consultant for Olympus and the recipient of minor foodand beverage from US Endoscopy, Abbvie, and Cook Med-ical. Dr Sejpal is a consultant for Olympus America andBoston Scientific. Dr Bernstein is a consultant for GileadSciences, AbbVie, Intercept Pharmaceuticals, and BayerHealth Care Pharmaceuticals. Dr Trindade is a consul-tant for Olympus America and Pentax Medical, the recip-ient of minimal food and beverage from Boston Scientific,TABLE 1. Characteristics of 111 COVID-19 patients undergoing urgent GI endoscopyCharacteristic All patientsPatients intubatedfor respiratory distressbefore endoscopy (n [ 29)Patients electivelyintubated (n [ 45)Patients withsedation (n [ 37) P valueAverage age, years (%) 63.5 (16.74) 64.5 (13.60) 61.6 (19.79) 65.2 (15.01) .36Gender female, % (n) 32.4 (36) 24.1 (7) 33.3 (15) 37.8 (14) .67Race, % (n) .005White 37.3 (41) 41.4 (12) 45.5 (20) 24.3 (9)Black 22.7 (25) 17.2 (5) 25.0 (11) 24.3 (9)Asian 10.9 (12) 13.8 (4) 0.00 (0) 21.6 (8)Multiracial/other 29.1 (32) 27.6 (8) 29.6 (13) 29.7 (11)BMI (SD) 29.9 (9.4) 29.4 (6.7) 32.2 (11.3) 27.7 (8.3) .06Charlson ComorbidityIndex, average (SD)4.28 (3.0) 3.69 (2.5) 4.04 (3.0) 5.03 (3.3) .16Comorbidities, % (n)DM 39.6 (44) 48.3 (14) 44.4 (20) 27.0 (10) .10HTN 57.7 (64) 62.1 (18) 60.0 (27) 51.4 (19) .43CAD 16.2 (18) 13.8 (4) 11.1 (5) 24.3 (9) .11CHF 9.0 (10) 6.9 (2) 8.9 (4) 10.8 (4) 1.00COPD 8.1 (9) 10.3 (3) 8.9 (4) 5.4 (2) .69Smoking 5.4 (6) 0 (0) 8.9 (4) 5.4 (2) .69Asthma 1.8 (2) 0 (0) 4.4 (2) 0 (0) .50OSA 0.9 (1) 0 (0) 0 (0) 2.7 (1) .45Cirrhosis 3.6 (4) 3.5 (1) 0 (0) 8.1 (3) .09Prior GI bleeding 7.2 (8) 0 (0) 4.4 (2) 16.2 (6) .13Kidney disease 15.3 (17) 6.9 (2) 17.8 (8) 18.9 (7) .89Cancer 18.9 (21) 13.8 (4) 17.8 (8) 24.3 (9) .47Abnormal CXR, % (n) 55.9 (62) 93.1 (27) 37.8 (17) 48.7 (18) .32Patient in ICU, % (n) 38.7 (43) 93.1 (27) 26.7 (12) 10.8 (4) .07ASA class, % (n) .611 3.6 (4) 0.00 (0) 6.7 (3) 2.7 (1)2 5.4 (6) 0.00 (0) 8.9 (4) 5.4 (2)3 46.9 (52) 10.3 (3) 53.3 (24) 67.6 (25)4 44.1 (49) 89.7 (26) 31.1 (14) 24.3 (9)Oxygenation statusbefore procedure, % (n)Nasal cannula 73.0 (81) 0 (0) 97.8 (44) 100 (37) 1.00Nonrebreather 0.9 (1) 0 (0) 2.2 (1) 0.00 (0) 1.00ET tube for respiratory failure 26.1 (29) 100 (29) 0 (0) 0 (0) N/AContinuous variables are represented as means (SD), and categoric variables are represented as % (n).ASA, American Society of Anesthesiologists Classification class; BMI, body mass index; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive lungdisease; CXR, chest x-ray; DM, diabetes mellitus; ET, endotracheal; HTN, hypertension; ICU, intensive care unit; OSA, obstructive sleep apnea.Letters to the Editor2 GASTROINTESTINAL ENDOSCOPY Volume -, No. - : 2020 www.giejournal.organd the recipient of research support from NinepointMedical. The other authors disclosed no financialrelationships.Praneet Wander, MBBSDivision of GastroenterologyLong Island Jewish Medical CenterZucker School of Medicine at Hofstra/NorthwellNorthwell Health SystemNew Hyde Park, New YorkDaniel E. Hogan, DODivision of GastroenterologyLenox Hill HospitalZucker School of Medicine at Hofstra/NorthwellNorthwell Health SystemNew York, New YorkSumant Inamdar, MDDivision of Gastroenterology and HepatologyDepartment of MedicineUniversity of Arkansas for Medical SciencesLittle Rock, ArkansasPetros C. Benias, MDDivision of GastroenterologyLong Island Jewish Medical CenterZucker School of Medicine at Hofstra/NorthwellNorthwell Health SystemNew Hyde Park, New YorkDivision of GastroenterologyLenox Hill HospitalZucker School of Medicine at Hofstra/NorthwellNorthwell Health SystemNew York, New YorkFady Haddad, MDSherif Andrawes, MDDivision of GastroenterologyStaten Island University HospitalZucker School of Medicine at Hofstra/NorthwellNorthwell Health SystemStaten Island, New YorkDavid E. Bernstein, MDDivision of HepatologyLong Island Jewish Medical CenterZucker School of Medicine at Hofstra/NorthwellNorthwell Health SystemNew Hyde Park, New YorkInstitute of Health Innovations and Outcomes ResearchFeinstein Institutes for Medical ResearchNorthwell HealthManhasset, New YorkDivyesh V. Sejpal, MDDivision of GastroenterologyNorth Shore University HospitalZucker School of Medicine at Hofstra/NorthwellNorthwell Health SystemManhasset, New YorkArvind J. Trindade, MDDivision of GastroenterologyLong Island Jewish Medical CenterZucker School of Medicine at Hofstra/NorthwellNorthwell Health SystemNew Hyde Park, New YorkInstitute of Health Innovations and Outcomes ResearchFeinstein Institutes for Medical ResearchNorthwell HealthManhasset, New York, USAand the Northwell COVID-19 Research ConsortiumREFERENCES1. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics,comorbidities, and outcomes among 5700 patients hospitalized withCOVID-19 in the New York City area. Jama 2020;10022:1-8.2. Gralnek IM, Hassan C, Beilenhoff U, et al. ESGE and ESGENA positionstatement on gastrointestinal endoscopy and the COVID-19 pandemic.Endoscopy 2020;52:483-90.3. Chiu PWY, Ng SC, Inoue H, et al. Practice of endoscopy during COVID-19pandemic: position statements of the Asian Pacific Society for DigestiveEndoscopy (APSDE-COVID statements). Gut 2020;69:991-6.https://doi.org/10.1016/j.gie.2020.06.039www.giejournal.org Volume -, No. - : 2020 GASTROINTESTINAL ENDOSCOPY 3Letters to the Editor

Elective endotracheal intubation for urgent gastrointestinal endoscopy among hospitalized patients with SARS-CoV-2

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Elective endotracheal intubation for urgent gastrointestinal endoscopy among hospitalized patients with SARS-CoV-2

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