- Safety first!
- Perform Hand Hygiene.
- Enhanced PPE is required for Aerosol-generating Medical Procedures (AGMP): N95 respirator or powered air-purifying respirator (PAPR) device, face shield or goggles, gown, and double gloves.
- Minimize providers in the room to the number necessary to provide safe intubation.
- Airborne infection isolation rooms, if available.
- Have an intubation plan; use a checklist.
- Assess for intubation difficulty.
- Early preparation of drugs and equipment.
- All necessary equipment is assembled inside the room.
- Standard monitoring.
- Connect viral/bacterial filter to circuits and manual ventilators.
- Use a closed suctioning system.
- A rescue plan for intubation failure
- Ensure team dynamics
- Five minutes of pre-oxygenation with oxygen 100% using a non-rebreather mask.
- Place hydrophobic filter between facemask and breathing circuit.
- Recommended by experts due to less aerosol generation.
- Might be non-sufficient.
Avoid the use of high-flow nasal oxygenation and mask CPAP or BiPAP due to a greater risk of aerosol generation.
EMCRIT mentioned the following approaches for Pre-oxygenation
NIPPV (Might be acceptable in a negative pressure room)
- A 2-tube system (closed circuit) with two viral filters.
- Place on CPAP/PSV, leave the PSV at 0, PEEP only if the patient’s saturations do not come up with 100% fiO2.
BVM with Viral Filter
- Turn BVM flow up to the flush rate.
- Place a NIPPV mask to allow good seal with you away from the patient or just hold two hands on the mask in a thumbs-forward grip from safer airways.
- The addition of nasal cannula underneath will allow CPAP with the PEEP valve if needed.
- Turn NC up to 4-6 L/m if this used.
Paralysis and Induction
- High-dose paralytic to inhibit cough.
- Appropriate induction agents.
- Head extension, often with flexion of the neck on the body.
- Full sniffing position with cervical spine extension and head elevation.
Placement of Tube
- The most experienced physician should perform the intubation.
Use video laryngoscopy rather than regular laryngoscope; to decrease exposure
- to patient’s aerosols.
- Allow the needed time after administration of the NMBA to ensure relaxation.
- Confirm placement of tube by visualization and EtCO2 rather than auscultation.
- Apply viral filter prior to bagging or connection to ventilation.
- Sedation and analgesia as indicated.
- ARDS ventilation setting with smaller tidal volumes (6 ml/kg of IBW)
- Decontaminate and disinfect all airway equipment.
- Appropriate doffing of PPE.
- Hand hygiene before and after all procedures.
References and Further Reading
- World Federation of Societies of Anaesthesiologists. [cited 2020Apr2]. Available from: https://www.wfsahq.org/
- Intensivist SWAED. COVID Airway Management Thoughts [Internet]. EMCrit Project. 2020 [cited 2020Apr2]. Available from: https://emcrit.org/
- Principles of Airway Management in Coronavirus COVID-19 [Internet]. Center for Medical Simulation. 2020 [cited 2020Apr2]. Available from: https://harvardmedsim.
org/blog/principles-of-airway- management-in-coronavirus- covid-19/
- Q & A on COVID-19 [Internet]. European Centre for Disease Prevention and Control. 2020 [cited 2020Apr2]. Available from: https://www.ecdc.europa.
- Walls R.Rosens emergency medicine: concepts and clinical practice – 2-volume set. Elsevier – Health Sciences Div; 2017