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SARS Update:
Focus on Airway Management
Robert C. Jones, M.D.
LtCol, USAF, Medical Corps
Staff Anesthesiologist
Andrews Air Force Base, Maryland
E-mail: [email protected]
Web site: http://www.notbob.com
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Overview
A Brief History of the 2003 SARS epidemic
 The SARS Virus
 Diagnosis
 Treatment
 Lessons Learned from China/Canada
 Airway Management Guidelines
 Discussion Issues
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Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Brief History of SARS
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? Zoonotic spread from unknown animal reservoir
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Brief History of SARS
? Zoonotic spread from unknown animal reservoir
 Nov 02: Index case in Guangdong Province, PRC; most
early cases among food handlers (civets, raccoons…)

Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Brief History of SARS
? Zoonotic spread from unknown animal reservoir
 Nov 02: Index case in Guangdong Province, PRC; most
early cases among food handlers (civets, raccoons…)
 Feb 03: Hotel Metropole, HK, PRC Physician from
Guangzhou (Superspreader) massive outbreak
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Hotel Metropole,
Kowloon, HK, PRC
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Brief History of SARS
? Zoonotic spread from unknown animal reservoir
 Nov 02: Index case in Guangdong Province, PRC; most
early cases among food handlers (civets, raccoons…)
 Feb 03: Hotel Metropole, HK, PRC Physician from
Guangzhou (Superspreader) massive outbreak
 Mar 03: Amoy Gardens outbreak  high prevalence of
diarrheal disease due to poor sanitation design

Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Brief History of SARS
? Zoonotic spread from unknown animal reservoir
 Nov 02: Index case in Guangdong Province, PRC; most
early cases among food handlers (civets, raccoons…)
 Feb 03: Hotel Metropole, HK, PRC Physician from
Guangzhou (Superspreader) massive outbreak
 Mar 03: Amoy Gardens outbreak  high prevalence of
diarrheal disease due to poor sanitation design
 Mar 03: SARS spreads to Beijing, Taiwan, Toronto, U.S.

Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Brief History of SARS
? Zoonotic spread from unknown animal reservoir
 Nov 02: Index case in Guangdong Province, PRC; most
early cases among food handlers (civets, raccoons…)
 Feb 03: Hotel Metropole, HK, PRC Physician from
Guangzhou (Superspreader) massive outbreak
 Mar 03: Amoy Gardens outbreak  high prevalence of
diarrheal disease due to poor sanitation design
 Mar 03: SARS spreads to Beijing, Taiwan, Toronto, U.S.
 Apr 03: Virus identified, sequenced in record time
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Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Brief History of SARS
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? Zoonotic spread from unknown animal reservoir
Nov 02: Index case in Guangdong Province, PRC; most early
cases among food handlers (civets, raccoons…)
Feb 03: Hotel Metropole, HK, PRC Physician from Guangzhou
(Superspreader) massive outbreak
Mar 03: Amoy Gardens outbreak  high prevalence of diarrheal
disease due to poor sanitation design
Mar 03: SARS spreads to Beijing, Taiwan, Toronto, U.S.
Apr 03: Virus identified, sequenced in record time
July 03: Epidemic declared over by WHO
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Timeline
774 Known
Dead (9.1%
fatality rate)
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
The SARS Coronavirus (SARS-CoV)
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Coronaviridae first identified in 1937 in chickens (avian infectious bronchitis)
Crown-shaped peplomers surrounding RNA source of name (Corona = Crown in Latin)
Responsible for common cold (2nd most common etiology after rhinoviridae)
Exact number unknown: many don’t grow in cultures
SARS virus can be grown in Vero culture (primate fibroblast cell line from 1962)
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Diagnosis: CDC
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Clinical Criteria
Asymptomatic or mild respiratory illness
Moderate respiratory illness
 Temperature of >100.4°F (>38°C)*, and
 One or more clinical findings of respiratory illness (e.g., cough, shortness
of breath, difficulty breathing, or hypoxia).
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Severe respiratory illness
 Temperature of >100.4°F (>38°C)*, and
 One or more clinical findings of respiratory illness (e.g., cough, shortness
of breath, difficulty breathing, or hypoxia), and
– radiographic evidence of pneumonia, or
– respiratory distress syndrome, or
– autopsy findings consistent with pneumonia or respiratory distress syndrome
without an identifiable cause
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Diagnosis: CDC
Epidemiologic Criteria
Travel (including transit in an airport) within 10 days of onset of symptoms to an area with current or previously
documented or suspected community transmission of SARS (see Table below),
or
Close contact within 10 days (one incubation period) of onset of symptoms with a person known or suspected
to have SARS.
Table. Travel criteria for suspect or probable U.S. cases of SARS
Area
First date of illness onset
for inclusion as reported
case‡
Last date of illness
onset for inclusion
as reported case†
China (Mainland)
November 1, 2002
July 13, 2003
Hong Kong
February 1, 2003
July 11, 2003
Hanoi, Vietnam
February 1, 2003
May 25, 2003
Singapore
February 1, 2003
June 14, 2003
Toronto, Canada
April 1, 2003
July 18, 2003
Taiwan
May 1, 2003
July 25, 2003
Beijing, China
November 1, 2002
July 21, 2003
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Diagnosis: CDC
Laboratory Criteria
Confirmed
Detection of antibody to SARS-associated coronavirus (SARS-CoV) in a serum sample, or
Detection of SARS-CoV RNA by RT-PCR confirmed by a second PCR assay, by using a second aliquot of the
specimen and a different set of PCR primers, or Isolation of SARS-CoV.
Negative
Absence of antibody to SARS-CoV in a convalescent–phase serum sample obtained >28 days after symptom onset.**
Undetermined
Laboratory testing either not performed or incomplete.
Case Classification***
Probable case: meets the clinical criteria for severe respiratory illness of unknown etiology and epidemiologic criteria
for exposure; laboratory criteria confirmed or undetermined.
Suspect case: meets the clinical criteria for moderate respiratory illness of unknown etiology, and epidemiologic criteria
for exposure; laboratory criteria confirmed or undetermined.
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Diagnosis: WHO
Suspect case
1. A person presenting after 1 November 2002 with history of:
- high fever (>38 °C)
AND
- cough or breathing difficulty
AND one or more of the following exposures during the 10 days prior to onset of symptoms:
- close contact with a person who is a suspect or probable case of SARS;
- history of travel, to an area with recent local transmission of SARS
- residing in an area with recent local transmission of SARS
2. A person with an unexplained acute respiratory illness resulting in death after 1
November 2002, but on whom no autopsy has been performed
AND one or more of the following exposures during to 10 days prior to onset of symptoms:
- close contact with a person who is a suspect or probable case of SARS;
- history of travel to an area with recent local transmission of SARS
- residing in an area with recent local transmission of SARS
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Diagnosis: WHO
Probable case
1. A suspect case with radiographic evidence of infiltrates consistent
with pneumonia or respiratory distress syndrome (RDS) on chest Xray (CXR).
2. A suspect case of SARS that is positive for SARS coronavirus by
one or more assays.
3. A suspect case with autopsy findings consistent with the pathology
of RDS without an identifiable cause.
Exclusion criteria
A case should be excluded if an alternative diagnosis can fully explain
(his or her) illness.
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Clinical Manifestations
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Incubation period: 2-10 days
Prodrome: 1-2 days
myalgia, fever, malaise
Fever > 38°C
Less commonly diarrhea
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Respiratory Phase: 3-7 days after onset; lasts to day 11-14
Cough, SOB, hypoxia
Severity varies
Falling SpO2 (<94%) ICU; SpO2 < 92% likely intubation
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Entire illness lasts 3 weeks if you don’t die; ? long term effects
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
Source: Loutfy, M, SARS: The Frontline Experience; Powerpoint presentation, 20 Oct 03
SARS
Clinical Manifestations (cont’d)
Extreme anxiety out of proportion to hypoxia
 Hyperglycemia
 Thrombocytopenia
 Leukopenia
 Lymphopenia
 Increased LDH, CK, ALT, lipase
 Increased severity in elderly (up to 50%
mortality > age 65); rare, less severe in children
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Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Radiologic findings
CXR: focal or multifocal
airspace disease/consolidation
 bilateral ground glass
opacities consistent with
ARDS/SIRS; may be NORMAL
High Contrast CT: can
determine disease in patients
with “normal” CXR;
parenchymal and airspace
disease evident
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Treatment
As of Nov 03, no specific treatment supportive
 Antibiotics: azithromycin, ceftriaxone not useful
against virus, may help if bacterial superinfection
 High-dose steroids in China avascular necrosis,
other side effects
 Ribavirin used not recommended (hemolytic
anemia)
 Experimental: TNF-alpha, protease inhibitors…
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Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Lessons Learned from China and Canada
Meta-Issues:
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Misinformation
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Lack of Communication
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Lack of Personnel
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Assumptions
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Transfers
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Post-Traumatic Stress
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Quarantine
 language issues, WHO travel warning in Toronto
 between countries, governments, hospitals  public health authorities
 underfunded health care system; unions and contracts; overtime issues
 Public health authorities assumed hospitals had adequate infection control
 ED  ward  long term care ED  other hospitals (lots of opportunities for infection)
 Health-care workers, civilians; stigmatization of subsets of populace (e.g., Chinese)
 Legal issues: Canada had no legal definition of quarantine pre-SARS; difficulties enforcing home
quarantine (e-mail, phone, videophone to read thermometer); people will cheat and go to work if not
given paid leave
 No wakes, ritual washing of body caused stress
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Lessons Learned from China and Canada
Hospital Infection Control:
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Wash your hands! Alcohol denatures proteins– good vs. enveloped viruses
Single entry point for staff separate from patients
Guard with personal protective equipment (PPE) to prevent unauthorized entry
Non-critical hospital staff (med students)  stay home
Strict no visitor policy (difficult to enforce with hospital personnel patients)
N95 mask + gown + no beards among ED staff for all patients during outbreak
Change PPE after every high-risk encounter (respiratory dz vs. ankle fracture)
Care with pens/cell phones/computers/pagers
No hallway stretchers
No humidified oxygen or nebs or BiPAP in ED  send to ICU
Limit staff contacts to minimum required for care (hard with sick colleagues)
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Airway Management
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High risk of transmission of SARS virus during airway
manipulation/intubation
5/50 intubations in Toronto  SARS transmitted  20
healthcare workers infected
Conflicts among staff to avoid being the laryngoscopist
for high-risk patients
Intubation rarely emergency in SARS gradual
decompensation over 12 hours should NOT be stat
procedure (takes 5 minutes minimum to don
appropriate protective equipment)
10-20% of patients will need to be intubated
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
High Risk Procedures
laryngoscopy
 intubation
 airway suctioning
 neb treatment (use MDIs instead)
 bronchoscopy (including fiberoptic intubation)
 bagging via mask
 emesis care
 anything that causes patient to cough
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Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Intubation Guidelines
Plan ahead! Will take at least 5 minutes to…
 Apply N95 mask, goggles, disposable footwear,
gown, gloves, belt-mounted PAPR (powered air
purifying respirator), head cover, extra gown,
extra gloves; if no PAPR N95 mask, googles,
disposable surgical cap, disposable full-face
shield
 Most experienced intubationist (not resident)
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Reference: Anaesthesia and SARS, British Journal of Anaesthesia 90: 6, June 2003, 715-718
SARS
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
Intubation Guidelines (cont’d)
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Avoid awake fiberoptic intubation; consider surgical airway
Plan for rapid sequence induction with skilled assistant available
for cricoid pressure; be generous with sux unless contraindicated
Minimal bagging pre-intubation: 5 mins preox with 100% FiO2
High-efficiency filter between facemask and bag
Intubate and confirm correct placement
Airway equipment sealed in double zip-locked bag and removed
for decon
Careful degowning/gloving with help of assistant
Wash hands with alcohol-based cleanser prior to touching hair
or face
Reference: Anaesthesia and SARS, British Journal of Anaesthesia 90: 6, June 2003, 715-718
SARS
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
Discussion Issues
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Everyone should read intranet resource: HCW Surveillance
Protocol for SARS– MGMC (links to CDC sources)
PAPR availability at MGMC: Ortho space suits are kept where?
Available to ED? Do we need to buy more for ICU, ED?
Infectious Disease consultants: WRAMC. Phone #s in ICU, ED?
ICU beds rate limiting step– 22 beds in Toronto’s North York
hospital maxed out…Transfer MOU with other hospitals?
Ambulance personnel trained/equipped (N95 masks, ?PAPR)?
Quarantine issues: If hospital quarantined, policies for paying
contractors, etc.? Sleeping arrangements, food, water?
Training: Should we try a SARS drill starting from ED ICU 
OR to see how we do? Probably as important as mock code blue
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS
Conclusions
“The only thing we have to fear is LACK of fear itself”
--former Deputy Treasury Secretary Lawrence Summers
• SARS will recur– and may recur forever
• SARS is a disease of healthcare workers out of proportion to the community
• Until there is an effective treatment or vaccine, SARS will remain a lifethreatening diagnosis
• The intangible costs of SARS (economic, post-traumatic) may rival the obvious
effects (morbidity, mortality); unknown long-term effects
• Protecting healthcare workers from SARS is difficult– takes time,
money, communication, planning, training, communication…
Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.
SARS