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.
Preparation
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
Pre-oxygenation
Non-bagging approach:
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.
Positioning
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.
Post-Intubation Management
Sedation and analgesia as indicated.
ARDS ventilation setting with smaller tidal volumes (6 ml/kg of IBW)
EM resident in ZMH, AD| Served in human rights and peace office IFMSA| Profound interest in education, critical care and disaster medicine| #FAOMed| Poet| Sarcastic in a good way|
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