Modified tracheal extubation for patients with COVID-19.

Editor—We read with interest the article by D'Silva and colleagues in the British Journal of Anaesthesia. They describe an extubation technique for patients with coronavirus disease 2019 (COVID-19) using two airway filters, with one attached to the tracheal tube and another attached to the facemask. We agree with the concept of using two airway filters for tracheal extubation and believe it is one of the safest ways currently described in the literature. However, we propose three modifications that we use at our institution when extubating patients with COVID-19 that improve upon the technique of D'Silva and colleagues.

Before extubation we recommend disconnecting the gas sampling line and moving it to the new filter attached to the facemask. This will allow for detection of end-tidal CO2 immediately after extubation. As the gas sampling line port is downstream from the filter, the port can either be left open or sealed with the plug that either comes attached with the existing filter or with the plug from the new filter. Second, instead of stacking the airway filters on top of each other we recommend discarding both the tracheal tube and its filter upon extubation. This results in the standard facemask, filter, and circuit setup that we find to be both less awkward and less likely to disconnect inadvertently compared with the double airway filter setup proposed by D'Silva and colleagues. Furthermore, using one filter will reduce the overall dead space of the circuit, which could be an important factor in paediatric cases. Finally, we recommend using a surgical mask with elastic ear loops attached to the patients' ears and under their chin before removal of the facemask so that it can be quickly positioned into place after facemask removal. Oxygen can then be applied either with nasal prongs as D'Silva and colleagues describe or with a simple oxygen facemask on top of the surgical mask. We have summarized these steps in Figure 1 . We thank D'Silva and colleagues for their article, and hope that our suggestions further improve upon the safety of their extubation technique for COVID-19 patients.

Fig. 1

Extubating COVID 19 Patients is a SNAPP. A – S - Sampling line attached to new filter. B – N – New filter is attached to circuit. C – A – Airway is removed. D – P – Place oxygen mask on patient. E and F – P – Pull surgical mask up and reapply oxygen mask.

Declaration of interest

The authors declare that they have no conflicts of interest.