Some thoughts from our recent experiences and courses…
1. Preparation
1.1. Make sure your team is operating based on a shared common mental model.
1.2. Eliminate variation, standardize your process and make it obsessively simple.
1.3. Run training/simulations in full PPE with ultraviolet tag germs (gel, powder and mist) to identify potential areas of contamination when the blacklights come on. I know that PPE can be hard to come by but so is your staff if they are home sick or worse yet dead.
1.4. Be meticulous about covering the neck and head, aerosolized virus will find its way there.
1.5. Run your airway training and simulations with a safety officer. You can also use a buddy system as observer as this provides additional reinforcement for the observer on what to do and what not to do.
1.6. Get used to wearing 2 pair of gloves as it gives you the ability to quickly strip off contamination. You can also clean gloves with alcohol sanitizer between activities on the same patient.
1.7. Skip any airway assessments (mallampati, LEMON, etc.) that will expose you to aerosolization. Go into every airway like it’s a potentially difficult airway and use the appropriate tools at your disposal.
1.8. If available at your facility, try to do intubations in negative air flow rooms if logistically possible.
1.9. Consider using the ROX index, the ratio of [oxygen saturation/FiO2]/respiratory rate to assess patient status.
1.9.1. The ROX score is useful clinically because it requires few data points and is simple to calculate at the bedside.
2. Identify Roles and Responsibilities
2.1. You will need to use your best and most qualified intubator. The intubator will need at least 1 assistant and ideally 2 assistants with them in the room.
2.1.1. Intubator – Intubators have one of the highest risks of becoming infected. Operator should be wearing a Powered Air Purifying Respirator (PAPR) due to being in the direct air stream wherever possible.
2.1.2. Assistant 1 – Responsible for the equipment setup, preparing ventilator, assisting with preoxygenation
2.1.3. Assistant 2 – Responsible for IV/IO access, drugs, drips, assisting w pre-oxygenation
2.1.4. Resources Outside Room – Have a runner for supplies, 1-2 additional staff in full PPE on standby
2.2. Large facilities are creating intubation response teams to maximize success and minimize risk.
2.3. Small facilities, critical access hospitals (CAH) and pre-hospital need to train for worst case scenario (i.e. middle of the night ED, only 1 MD, 1 RN and 1 CNA or for EMS with 1 Paramedic and 1 EMT)
2.4. If resources allow, have a safety officer / observer watching donning and doffing (Especially Doffing!), passing equipment, supplies and drugs from clean to dirty.
2.5. Make sure you have an airway plan in place for your patient. Consider what are your sequence of steps, number of attempts and timing of escalation prior to entering the room. What are you prepared to do to secure this airway?
3. Equipment
3.1. Beware of reaching into bins, shelves, boxes and drawers. This is a common mechanism of cross contamination
3.2. Minimize room/rig/aircraft stock to limited number of items to avoid contamination from contact or aerosolization.
3.3. Video Laryngoscopy (VL) is the preferred method of intubation, Direct Laryngoscopy (DL) should be avoided where possible.
3.4. Ideally the VL that should be used has a separate video screen to keep intubator out of this direct airflow.
3.5. Creative draping can help decrease the amount of aerosolization. One method is to cover the patient’s upper torso with a clear drape/bag drape and have intubator reach under the drape to intubate.
3.6. Although an ET is preferred, where a supraglottic airway is required, use of a second-generation device (wedge shaped heel of mask for seating at base of tongue) is recommended. It has a higher seal pressure during positive pressure ventilation decreasing the risk of aerosolization of the virus. Place viral filter on device prior to insertion.
3.7. Due to code cart and airway cart contamination by opening it in COVID19 room with aerosolizing procedure, most (hopefully all!) facilities are removing carts from rooms.
3.8. Now is the time to ensure that your bag valve mask’s (BVM) have the ability to deliver PEEP. I am still amazed at the numbers of facilities that don’t have this simple capability.
3.9. Ventilators
3.9.1. Having viral filters on ventilator circuits and between bag valve and mask is mandatory! Place the viral filters as close to the patient as possible.
3.9.2. Distal to the patient viral filter attach inline suction catheter where available. This eliminates the need to break the circuit to suction patient.
3.10. Have padded large hemostats available. Once intubated, anytime ET tube is disconnected from vent circuit, it should be clamped. This includes changing from BVM to ventilator and also transport ventilators to hospital ventilators.
3.11. Stage your equipment kits based on need.
3.11.1. Airway Option 1 – Standard Intubation Kit should be in the room with you.
3.11.2. Airway Option 2 – Rescue Airway Kit (2nd Generation LMA’s, possibly Kings) should be outside room and ready to go. Place the viral filter on the device prior to insertion.
3.11.3. Airway Option 3 – Emergent Front of Neck Access (eFONA) Kit should be outside room and ready to go. “Scalpel Finger Bougie” to keep it simple for everyone
3.11.3.1. eFONA Kit Contents – Number 10 Scalpel Blade, Bougie and a 5.5, 6.0 and 6.5 ETT’s
4. Pre-Oxygenation
4.1. Options – Use negative flow room if immediately available.
4.1.1. Option 1 – Patients on nasal cannula oxygenation at 5-6 LPM with surgical mask placed over cannula to capture droplets.
4.1.2. Option 2 – BVM, use the 2 Thumbs Up Method for the best mask seal. Once mask is on the patient’s face, do not break the seal! If BVM oxygenation fails, strongly consider going directly to Option 4
4.1.3. Option 3 – CPAP (Maybe…)
4.1.4. Option 4 – 2nd Generation LMA if oxygenation is failing with CPAP or BVM. Viral filter on device prior to insertion.
4.2. Start pre-oxygenation early so intubation can be under controlled circumstance rather than waiting until it is a crisis.
4.2.1. Anecdotally there have been a number of reports where patient numbers (pulse oximetry and ABG) are in the toilet but they do not appear dyspneic. Not sure what to make of this… there are people way smarter than I am looking into this.
4.3. Optimize position, reverse Trendelenburg and/or ramp the patient up to 20-30 degrees. This will gain you some alveolar recruitment as well as help reduce risk of aspiration.
4.4. Try to minimize aerosolization producing activities like non-rebreather masks, BiPap, etc.
4.5. Consider humidification of oxygen. This comes from a recent call that mentioned that moisturized aerosol potentially would not travel as far as dry aerosol
5. Medications
5.1. RSI – Use Simplified and Standard Drugs (see Simplified RSI table at the end)
5.1.1. Ketamine – Simple Dosing
5.1.1.1. Up to 100 kg give 100 mg
5.1.1.2. Over 100 kg give 150 mg
5.1.2. Rocuronium – You want fast and complete paralysis
5.1.2.1. Recommendation has been for Rocuronium 1.2 to 1.5 mg per kg
5.2. Consider using a one gallon Ziplock bag with initial RSI Drugs. For additional meds, runner/pharmacy passes to patient room.
5.3. Plan on hypotension. Have push dose pressors (Epinephrine, Neosynephrine or Ephedrine) and a bag of Norepinephrine mixed up and ready to go.
5.4. Consider fluid sparing approaches where possible. Evidence suggests that these patients do better if ran on the “dry” side.
5.5. Make sure you have 2 great IV/IO’s
5.6. Once patient is intubated, what is your sedation plan for them while on ventilator?
5.6.1. My preference would be start with Fentanyl. Tendency to avoid benzodiazepines due to delirium, mortality, vent days, etc. Due to potential shortages of all sedation drugs, you may have to use what you have available.
6. Intubation
6.1. Anticipate rapid desaturation.
6.2. Try to keep patient as upright as possible during intubation. At the very minimum ramp them 20-30 degrees.
6.3. Once patient is intubated, gently remove stylet/bougie, clamp ETT, inflate cuff, attach ventilator circuit, unclamp ETT
6.4. Do not pull stylet straight up. Pull stylet up and curve towards patients’ feet. Like you are removing sword from sheath.
6.5. Confirm tube position by waveform capnography.
6.6. If you have it available in the room, it is possible to check placement using ultrasound (Study 1 , Study 2)
6.7. Plan to get portable CXR ~15 minutes after intubation to allow time for stabilization
7. Post Intubation
7.1. Once the patient is intubated, closed suction systems should be used to minimize aerosolization of the virus.
7.2. Consider doing other procedures that the patient may require after intubation. Plan for patient’s need for central lines, art lines, etc. and do them after intubating patient.
7.3. Cuff manometer should be available to measure tracheal tube cuff pressure in order to minimize leaks and the risk of aerosolization of the virus.
7.4. A naso / orogastric tube should be placed at the time of intubation to avoid further close contact with the airway.
7.5. Be prepared to prone patient
8. Ventilators
8.1. COVID-19 Ventilator Mortality Rates
8.1.1. 1. Kirkland 52.4%
8.1.2. 2. Seattle 50.0%
8.1.3. 3. UK 66.3%
8.1.4. 4. China 86.0%
8.2. Consider your ventilator settings very carefully. Experts recommend settings based on ARDSNet tables.
8.2.1. Patients appear to be in ARDS but with better lung compliance
8.3. Splitting Ventilators – There is a lot of out there regarding the pros and cons of splitting ventilators. I acknowledge it is not optimal and it takes advanced skills to make it work. Below I have listed some of the best resources I have been able to find both for and against.
8.3.2. PulmCrit – Splitting ventilators to provide titrated support to a large group of patients
8.3.3. Medium – A better way of connecting multiple patients to a single ventilator
8.3.4. EMCrit 269 – Rationing of Critical Care and Ventilators in COVID19 with Reub Strayer
8.3.5. Shared ventilation: how to do it if you have to
8.3.6. Should we put multiple COVID-19 patients on a single ventilator?
8.3.7. Ventilator Sharing Protocol
9. Extubation
9.1. Consider 2% lidocaine down the ETT 15 minutes prior to extubation to reduce coughing.
9.2. Consider low dose Fentanyl IV to decrease cough.
9.4.
10. Debriefing
10.1. Debrief immediately after intubation complete
10.2. Follow a simple process and document
10.2.1. Is everyone ok?
10.2.2. What went well?
10.2.3. What could we have done better?
10.2.4. Were there any issues around
10.2.4.1. People
10.2.4.2. Process / systems
10.2.4.3. Materials / supplies. etc.
10.2.4.4. Other learned experiences
10.2.5. What needs to be followed up on or addressed
