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.
8.3.1. PulmCrit wee – Why the SCCM / AARC / ASA
/ APSF / AACN / CHEST joint statement on split ventilators is
wrong
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






