This page will serve as the repository of COVID19 airway management thoughts and recommendations. Each time I post something new, it will exist as a separate post for a week and then be merged into this page.
We are at Risk
El-Boghdadly et al. estimated around 1 in 10 intubations would lead to infection [10.1111/anae.15170]
PPE – What to Wear
- N95 (add a PAPR if available to the N95)
- Surgical Mask over N95
- Goggles that surround eyes with facial contact, face shield, or full joint-replacement-hood with visor (full face coverage desperately preferred)
- Bunny suit, preferably with hood or disposable fluid-proof gown
- Something to cover your neck if not in hood
- If no hooded suit available, disposable cap
- 2 pairs gloves, 1 under sleeves of bunny suit or gown and 1 over, under-layer gloves would ideally be long cuffed
- Booties are a big doffing risk, so wear shoes you can disinfect
All of this is based on no evidence (there are no evidence-based strategies out there)
This has been the most recommended strategy in articles/write-ups, but in my mind, it may be the worst of the viable options. To get a decent fiO2, you will need to crank it up to flush rate and I am not sure what effect that will have on the patient’s exhalations becoming aerosolized.
This has been panned for potential to increase risk to providers—however, that is predicated on passive exhalation systems (i.e. vents exhalation goes to the environment and has only 1 tube). However, a 2-tube system is a closed circuit. With the addition of 2 viral filters, this may be acceptable in a negative pressure room. It can also be left on during the apneic period with a jaw thrust. Place on CPAP/PSV, leave the PSV at 0, dial up PEEP only if patient’s saturations do not come up with 100% fiO2.
Critical Note: If you use the vent for preox, you MUST disconnect the vent circuit proximal to the viral filter before removing the mask. Otherwise, COVID will be sprayed all around the room!!!!! See Triple C below.
BVM with Viral Filter
- If you don’t have a vent available
- Turn BVM flow up to flush rate, higher flows do not translate to patient end of the bvm
- Place viral filter between BVM stem and mask
- Ideally, a NIPPV mask should still be placed to allow good seal with you away from the patient or just hold two hands on the mask in a thumbs-forward grip
- Addition of nasal cannula underneath will allow CPAP with PEEP valve if needed. I would only turn NC up to 4-6 lpm if this used. Often NC fits with no mask leak. More preferable is porting the oxygen through a luer or pressure connection port.
The first video uses a nasal cannula, the second avoids the NC leading to even less mask leak:
The Nasal Cannula Video (Next Video avoids using Nasal Cannula)
EMCrit CPAP Set-Up without the NC
Here is a Pict
Here is a Pict with the 22mm OD Male-to-Male Connector and Corrugated Tubing
UMich Graphics from Hsu et Al.
Wilson Lam explains the set-up in a video
Better way to use the 3-way Stopcock
I showed in the video that you can use O2 tubing with 3-way stopcock but there is a clean oxygen leak. Bill Murphy, medic extraordinaire, wrote me with a better way. Cut off the fat part of the O2 line. You need to test with your hospital's lines to find out the best place to cut, but once you get rid of protrusion, you can make a tight connection without the multipurpose tube to luer adaptor.
Special Made Adapter
You can get a fitting specifically for O2 lines
Critical Note: When ready to intubate, disconnect BVM from viral filter to depressurize the set-up before removing the mask
Video Proving that BVM alone doesn't supply enough forward flow
and that even on flush-rate doesn't provide dangerous flow to patient to cause aerosol
George Kovacs' Proof of Apneic CPAP Efficacy with this Set-Up
Stacey Turner goes through all of the Equipment Permutations
Your safety then their safety
Go to the Protected Code Blue Page for full info [link pending]
COVID Intubation Packs
Goal is to avoid having to look for any items once in a COVID19 patient's room and make protective-preox equipment immediately available.
COVID/PUI Intubation Pack
- Place in Large X-ray Ziplock BagAdult BVM
- Face-Shield/Knights Helmet or Hood
- Multi-purpose Adaptor
- Oxygen Tubing
- ETCO2 Adaptor
- ETCO2 Tubing
- Yellow Viral Filter
- ETAD Tube Securement
- In-Line Suction
- Flex Tip Bougie
- PEEP Valve
Besides the pack, you will need intubation meds, a video laryngoscope and either a medium or large (depending on patient) non-vented bipap mask
Throat and Cord Swelling
Many have reported that these patients may have soft tissue swelling as a result of COVID. Be aware before going in that tissues may be swollen. I personally prefer a bougie in these patients.
- Make a cell phone call to a buddy who will stay outside the room and then put your phone on speaker in your chest pocket to allow continuous communication
- RSI with high-dose paralytic, ketamine is preferred induction b/c if patient is not compliant with preox, perform immediate ketamine dissociation for DSI
- BVM or Vent for Reoxygenation (only if needed!) with viral filter at the wye of vent or stem of BVM, can be by mask or LMA. EtCO2 monitoring should be behind the viral filter to allow monitoring of mask/LMA seal, both for REOX efficiency and team safety—i.e. a crappy seal puts you and the patient at risk. (best option is apneic CPAP reoxygenation–see video above)
- Highest-Level Physician (attending level) should do the Intubation
- Use CMAC or Glidescope with new bougies to maximize 1-attempt success
- Visualize black line of ETT at level of cords to avoid having to auscultate for depth
- Cuff fully inflated and viral filter on the ETT prior to bagging/hooking to vent
- Confirm with ETCO2, not auscaltation
A number of ideas have been floated:
Vent Settings and Post-Intubation Management
- Strict ARDSnet settings [see COVID Ventilation post–link pending]
- Call ED Critical Care Staff and/or MICU Fellow/Attending if PEEP required hits 20 cm H20
- Tube should be clamped or have the viral filter on for any vent disconnects (see triple C below)
- If suction is used, it should be closed circuit suction
How to Nebulize if we really, really think it is a good idea
- Don't use NEBs in any situation that MDI can be used!
- Appropriate only if you think the patient is low-risk for COVID, i.e. an asthmatic or COPD patient with a cough, but no other worrisome signs
- Should only be done in neg-pressure room
- Equipment needed:
- NIPPV masks (unvented)
- Multi-Adapter – 15mm ID X 22mm OD (resp has these)
- Nebulizer set-up
- Viral filter
Update: Now the COVID is going endemic, I really don't think nebs are a great idea! Use MDIs or parenteral meds. While the just-mentioned method will work, it potentially burns a viral filter and NIPPV mask. Consider saving these items in case the patient decompensates.
- All of the above sections mentioned viral filters.
- The high-efficiency version we use at Janus General is the
rated for 99.999% filtration of viruses
- Your respiratory department should have similar filters available
- YOU MUST CONFIRM THAT YOUR HOSPITAL'S FILTERS ARE SUFFICIENT FOR COVID19
- This is a potentially high-risk moment. Follow ED Policy with a spotter to avoid contamination after successful airway management. Use a buddy!!!!
“Triple C” Circuit Disconnects
May be even higher risk than intubation if you do it wrong
Preplan with your partner
Either non-marring clamp or clamp around 4×4 or tape on ETT (if disconnecting proximal to viral filter, than you can ignore the clamp)
Put the vent in standby or disconnect the inspiratory limb
Study demonstrating ECMO Clamps are the best clamps (but we Pump-Heads already knew that)
Original Wee with Brian Wright
This was recorded before the surge: Initial COVID Airway Managment Thoughts
Safer Airway Society Guidelines
By a bunch of my SMACC airway buddies
- Prepress Version
- There is also a link to the article as well as printable infographics at the SaferAirways Site
Please Peer Review with Comments Below
Now on to the Podcast…
- EMCrit 279 – The Decision to use Ketamine – Disruptive and Dangerous with Reub Strayer - August 9, 2020
- EMCrit 278 – Labors of Trauma – Blunt Edition (Part 1) - July 24, 2020
- EMCrit 277 – COVID Pulmonary Physiology with Martin Tobin - July 9, 2020