Supraglottic Devices in Children during the COVID-19 Pandemic

To the Editor:

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has resulted in a number of infections and deaths of health workers. Although the disease has a more benign course in the pediatric population, children are an important source of infection. Data from the SARS CoV-1 epidemic reveal that procedures that generate aerosols and respiratory droplets are those with the highest risk of contagion for health workers [1]. Some guidelines and protocols on the management of pediatric patients in this new context recommend tracheal intubation in children suspected of or positive for coronavirus disease 2019 (COVID-19) as a protective measure for those who attend the airway and a laryngeal mask as rescue device. However, there are many short-term surgical or diagnostic procedures that require general anesthesia in children in whom this recommendation is questionable. The use of supraglottic devices (SGD) could be a better alternative for patients and health workers.

In pediatric patients, tracheal intubation and subsequent extubation generate a higher risk of laryngospasm, bronchospasm, airway obstruction, and cough than SGD [2]. These situations force the provision of positive pressure ventilation (PPV) with face mask or re-intubation, which are aerosol-generating procedures, increasing health workers exposure and risk of contagion. Although it is true that gas leakage with SGD is greater than with the tracheal tube and may be an additional source of aerosols, this risk may decrease if second-generation SGD with higher leak pressure are used [3,4] and spontaneous ventilation is maintained. In addition, the insertion of the SGD is faster than tracheal intubation, does not require neuromuscular relaxation, and can be performed in spontaneous ventilation. This is relevant if you want to avoid the use of PPV because the apnea times without hypoxia are shorter in children and decrease more if there is ongoing respiratory infection. Safety can be increased if other recommendations are followed, such as the use of protective barriers (aerosol box or plastic covers) and viral filters.

Therefore, in the absence of studies comparing SGD and tracheal intubation in terms of risk of contagion for health personnel, it is reasonable to consider second-generation SGD as a good option to decrease the risk to health workers during short procedures in children requiring general anesthesia.