The following are airway management steps for patients with suspected COVID-19 infection.
Phase 1: Preparation (outside the room)
When managing the airway and
planning to intubate a suspected or confirmed COVID patient in the ICU
setting, the following steps are recommended. Intubation is considered an
aerosol generating procedure therefore ideally this will occur in a
negative pressure isolation room, or alternatively, a single room with the
door closed throughout. The code cart is placed outside of the room.
PPE materials should be readily available for 3 to 5 providers on code
carts. The intubation team should be optimized and ideally limited to 3 to 5
providers inside the room. Backup should be available outside the room. If a
difficult airway is anticipated, then calling for anesthesia or Otolaryngology
help early is recommended because of delays with PPE donning. A clear plan of
action should be articulated between the team as part of preparation outside the
room. The intubating team should don PPE
outside the patient's room. The team at the cart is responsible for prepping
medications and airway supplies while the intubating team are donning.
All medications for rapid sequence intubation including full dose muscle
relaxant, and any supportive medications, such as code meds, if deemed necessary,
should be labeled and brought to the bedside.
Various sizes of cuffed endotracheal tubes, oral airways, and supraglottic
airways should be available.
Phase 2: In-room Preparation After Donning
Intubating team roles include the laryngoscopist, who should be the most
skilled proceduralist, likely the ICU attending, an airway assistant, likely the
respiratory therapist, a nurse for medication administration, an event
manager, such as a nurse practitioner or senior fellow, may be inside the room
depending on attending preference. The respiratory therapist will check and
assemble airway equipment ensuring that the anesthesia bag setup, such as a
Jackson Rees circuit, has a HEPA-approved viral filter at the patient end,
that the ventilator is set up and ready with a viral filter on the expiratory
limb of the circuit, and end tidal CO2 monitoring is calibrated and warmed,
ready for use on the ICU ventilator. Inline suction is in place and the
endotracheal tube tape is also prepared. If a non-mainline end tidal CO2 system
is used for monitoring, then additional precautions to prevent ventilator
contamination will be necessary. The nurse will prepare a MEDLINE for drug
administration, and confirm working IV access. The laryngoscopist will optimize position
and pre-oxygenate the patient using the lowest flow that is considered safe, and
necessary to maintain oxygenation. A good mask seal should be maintained.
This is optimized with a two-hand technique. Positive pressure ventilation via bag
mask ventilation is avoided, if possible, to minimize aerosolization, and if it's
needed, the minimum rate and volume of positive pressure breaths should be
given. If the event manager is in the room, they should be positioned as far
from the airway as possible. If inside the room, they will turn the video scope
on, ensure it is plugged in, and in appropriate position. Use of video
laryngoscopy is recommended to maximize success and also allow a greater
distance between the proceduralist's face and the patient's airway.
Phase 3: Intubation
Communication during this phase is essential. When you're
ready to begin induction, the nurse will administer rapid sequence intubation
medications, including full doses of paralytics. Rapid sequence induction, with
or without modification, is preferred. The laryngoscopist will avoid manual hand
ventilation if possible as saturations allow, as masking may increase
aerosolization. This may potentially mean brief desaturation. Apneic oxygenation may
be considered, with understanding that it could potentially
negatively impact mask seal. If needed, use the minimal rate and volume of
positive pressure breaths required. Intubation is performed as the patient
becomes apneic. The fresh gas flow is turned off, just as the laryngoscopist
removes the mask from the patient's face to minimize aerosolization.
Laryngoscopy and intubation should be performed with indirect viewing and
on-screen confirmation of the endotracheal tube placement through the
vocal cords. The respiratory therapist will immediately inflate the
endotracheal tube cuff and then remove the stylet. The respiratory therapist
will connect the ventilator circuit directly to the patient and initiate
ventilation. The ventilator is immediately connected to minimize
further disconnections. Positive pressure ventilation using the ventilator is only
instituted after the cuff has been inflated. The respiratory therapist will
confirm endotracheal tube intubation by presence of end tidal carbon dioxide
on the ventilator capnograph waveform, and with misting in the
endotracheal tube. Confirmation by auscultation should be avoided as
possible, to avoid further exposure. The Laryngoscope blade remains in the
patient's upper airway, confirming the endotracheal tube remains in situ.
The respiratory therapist assumes control of the endotracheal tube so the
laryngoscopist can remove the blade from the mouth, disconnect the blade, and place
it into the designated container for cleaning and disinfecting.
The respiratory therapist and nurse then secure the endotracheal tube.
If intubation is not achieved, call for help early and avoid multiple intubation
attempts. Insert a supraglottic airway to improve oxygenation and avoid mask
ventilation.