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.
For the Most Comprehensive Info on COVID19, go to Josh's IBCC Chapter
We are at Risk
Inutbations
- El-Boghdadly et al. estimated around 1 in 10 intubations would lead to infection [10.1111/anae.15170]
Non-Rebreather Masks
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
Preoxygenation
All of this is based on no evidence (there are no evidence-based strategies out there)
Non-Rebreather
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.
NIPPV
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.
High-Flow Nasal Cannula
Aerosol risk seems no greater than standard NC and is mitigated by surgical mask (https://ccforum.biomedcentral.com/articles/10.1186/s13054-021-03512-w)
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
from Safer Airways - 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.
Optimal Preoxygenation
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
Anecdotal Evidence of Efficacy of the CPAP Set-Up
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
Cardiac Arrest
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.
Intubation Strategy
- 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
Aerosol Protection
A number of ideas have been floated:
- Garbage bag over the patient's head with arm holes
- Lucite cube
- Aerosol Block
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
Miscellaneous
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.
Viral Filters
- All of the above sections mentioned viral filters.
- The high-efficiency version we use at Janus General is the
Intersurgical Filta-Guard
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
Doffing PPE
- 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
Confer
Preplan with your partner
Clamp
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)
Cut Flow
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
Resources
Publications
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…
Podcast: Play in new window | Download (Duration: 15:10 — 14.3MB) | Embed
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Professor
Chief, Division of Emergency Critical Care
Director, Resuscitation and Acute Critical Care Unit
Stony Brook Medicine
Stony Brook, NY, USA
No conflicts of interest (coi).
[…] EMCrit: Some Additional COVID Airway Management Thoughts […]
Great points. Is anyone using an additional filter on expiratory limb as an additional precaution?
Also consider placing vent into standby when changing from transport vent to ICU vent or vice versa.
Stand-by is a must use option for VTR change to/from transport; extreme care for swivel end (attaches to ETT) as well since likely to have fluid dripping. Some VTRs have their own heated (designed to dry exhaled condensation) exhalation filter but we tend to add another one on exhalation inlet. VTRs that don’t have an inner filter get 2 now; one at the wye and second right before exhalation inlet. There is some good and bad to this….exhaled resistance, potential for air-trapping/auto-peep & its hemodynamic effect; how often to change them; how to change them quickly while VTR on stand-by… Read more »
Why would one want to put an extra HEPA filter on expiration. Also other have mentioned clamp the ETT, that just leaves a risk for Pneumothorax. If the patient is breathing over the vent. NIV has been contraindicated for Covid19 do to the high flow and even HFN is not being chosen. Why? Patients tend to deteriorate fast with this disease.
Hi all
Great stuff Scott – very similar to the approach we are adopting at our ICU.
Anyone aware of any evidence about whether a viral filter added to BVM can cause problems for pre-ox of spont breathing patients due to increased resistance?
Cheers
Chris
I can only tell you I breathed through one yesterday for 10 minutes to test the above. It was inconsequential resistance difference for me–can’t answer for sick pt. But they only need 250 ml/minute, so just can’t see how it could be a big problem.
In Canada everywhere I’ve worked all our BVMs come supplied with a filter in-line.
Scott, keep in mind that your peep valve is only going to maintain some CPAP when there’s flow going through it- pt exhalation or np under mask. I know you have stated the same before.
Question, what if we take home cpap units, turn them all the way down, put two viral filters inline. One at machine and one at mask. Inhaled air will be effectively filtered. Exhaled will go out exhalation port. Positive pressure will prevent virus from getting to you as well as the additional viral filter. We can put the cpap machines on portable battery machines they normally use for computers on wheels. We can then go room to room without needing to waste masks that are in short supply. Would have to be on a floor that has only Covid patients… Read more »
Did you ever find out if this would work?
I’m curious why no one appears to be using military gas masks (Ottawa, Canada police excepted) . They seem to be completely overlooked but they’re comfortable enough to work in for 12hr shifts, easy to expedient decon, rugged, and the government have plenty of spare filters. I stumbled this page because like many civilians my filters have expired dates (no big deal since not facing nerve agent) and I was curious to add a viral prefilter. Gas masks have fast acting check valves so a viral filter expediently mounted (grommet, hose barb etc) to the NATO canister would not be… Read more »
For oxygenation, can anyone comment on the use of a BVM with CPAP mask but NO PEEP valve is available yet. I would also add N/P at 5-6 l/min.
Is it safe?, does it work? do I need full PPE? or just a surgical mask unless intubating.
thanks. Is the PEEP valve crucial or would it likely still be effective?
Greg
the problem with home cpap units Is that they are single limb circuits so if using a full face mask need a vented mask or need to add a whisper swivel or expiratiory limb that you can make sure expiration is filtered
Other issue becomes amount of O2 that you can supply. You can’t get higher FIO2’s that may be required
I want to bring up an issue that we have found when placing the viral filter between the ET tube and the BVM. In the case of cardiogenic shock and a sudden onset of Flash Pulmonary Edema, the filter becomes wet and will no longer allow inspiratory breaths and builds up pressure in the BVM which can lead to failure. This becomes a problem and increases rick of exposure due to the need to repeatedly break the circuit and replace the filter.
this is not a problem only of this set-up but any set-up in which there is a distal viral filter. we use the same distal filter on our ETT with mech vents. We put a HME between tube and viral filter. but then you still have to change out the hme. there is no solution that is viable to avoid this
I believe I have a solution for the BVM. I would like to send a picture and see what you think. How can I do this?
Scott
Great post- thanks for putting this out there.
One comment- The suggestion of a NC underneath a BVM mask that is only flowing 4-6 LPM may actually be deleterious to pre-ox rather than help, at least based on this healthy volunteer study by Claire Hayes-Bradley. Putting a NC on at 0 or 5 LPM actually decreased average end-tidal O2 readings by a mean of 7%. It seems that you need at least a flow of 10 LPM to be non-inferior to BVM+NC at 15 LPM or just a BVM by itself.
https://www.ncbi.nlm.nih.gov/pubmed/28759496
Hey Scott! About bronchspasm management, we decided to use MDIs whenever possible as you said but also try to optmise IV pharmacological treatments that may not have a good evidence. Like MgSO4 and Azythromicin – again not so much evidence. Holding steroids whenever possible. However we understand that in a case of COPD and Asthma patient with COVID19 and severe bronchspasm or a low SpO2, the better management, although more difficult would be to intubate it and use IV bronchodilators such as adrenaline as a continous infusion or salbutamol (understanding that the latter may not be well tolarated in an… Read more »
What type of face shield/goggles are people looking at? My hospital has already run out of protection so I’m thinking to get a pair for myself, even with reuse/cleaning with chem-wipe still will be better than nothing.
Have you been using IM or IV epi for COVID patient’s with reactive component to avoid nebulizers? If so, does your facility have a protocol? For IM are you using the 03.-0.5mg dosing?
[…] more FOAMed on airway control in COVID-19, check out EMCrit and Life In The Fast […]
1) Can we really hang our hat on (+) viral panels to r/o SARS-CoV-2. Case reports of Flu/SARS-CoV-2 co-infections are trickling out?
2) For the non-crashing patient without cardiac disease who needs more than just steroids and an MDI. I have been using using a Mdi’s + IM anaphylactic dose epinephrine.
3) If we have a person under investigation (PUI),… who is not crashing——is the HPI, x-ray, labs, +/- CT chest——WITHOUT THE PHYSICAL EXAM acceptable
suggest posting these comments on the ibcc COVID19 page
Of course. We are ER docs. Physical exam is optional.
C PAP machines – potentially helpful / a tool / for those with breathing problems due to Covid 19 , or potentially harmful?
In Italy +80 year old patients can’t get helped anymore because they are out of ventilation machines. But can’t other countries help with sending them or even CPAP machines?
I wondered the same thing. If it saves 1 life it’s worth it.
I’m just a lowly Street Medic but, what are your thoughts of going back to Terbutaline for initial treatment of Bronchospasm in the acute setting?
Last I really looked at it I was getting it removed from the trucks since it had very similar MOA, onset, and peak with Albuterol making it a waste of money.
Is the filter setup compatible with closed inline suctioning?
There appears to be a neurological component of covid 19 which may explain the mechanism behind the respiratory distress for some patients. We still don’t know why some patients stop breathing but brain stem involvement may be why. Please check out this new research which does a better job of explaining it than I can. It also gives support to the hypothesis that CPAP machines could be useful in this crisis.
Sorry here’s the research article I referred to:
Journal of Medical VirologyEarly View
REVIEW Free Access
The neuroinvasive potential of SARS‐CoV2 may be at least partially responsible for the respiratory failure of COVID‐19 patients
Yan‐Chao Li Wan‐Zhu Bai Tsutomu Hashikawa
First published: 27 February 2020
https://doi.org/10.1002/jmv.25728
The list is missing a bib for the faceshield if no full hood: Necks are covered in germglo ( or whatever the stuff is called) after simulations.
Interesting, do you have a source for these simulations?
Watched the video and as an RCP for 41 years this works. The modifications we make are to add 6 inches of corrugated tubing and 15/22 mm adapter from the mask to the ambu bag so you are not on top of the patient. Could breathe easy with this addition and provided sufficient PEEP. Did take out the CO2 monitoring as we just don’t have enough to use in these cases. This will be used to increase oxygenation and bagging until we can move the patient to an ICU or ED and intubate. or for EOL care when ventilators are… Read more »
[…] 4. https://emcrit.org/emcrit/some-additional-covid-airway-management-thoughts/ […]
[…] Idea and Image from Scott Weingart, MD from EMCrit Website […]
Greetings,
So I came here from the Intubation pack video.
One small correction. With the spring PEEP valve, there is no such thing as “zero” peep if it is on the exhalation port. Even at it’s lowest setting, it is still providing about 2-5 cm H2O peep. The only way to get “zero” peep is to remove it, though you will still have some small resistance from the one-way valve from the BVM.
I do not know if this would be disadvantageous, or even clinically significant, but wanted to encourage a bit of accuracy.
Thanks
Steve
all depends on the individual valve, but most of them may apply a little. ours is 2 cm/h20
Hey good stuff
If using the BVM/entrained O2 setup detailed above not just for preintubation oxygenation, but for proposed non invasive vent, do you have any ideas for titrating Fi02? (Other than guessing by entraining air instead of 02…)
What is your plan b for failed intubation? How would you manage a CICO situation in a covid-19 patient?
Because of the severe bronchorrhea in these patients would you recommend etomidate rather than ketamine. I preferred ketamine as my go to RSI Ned for most things but wondering if This would be the case to switch.
How many of the CPAP circuits are people putting together on an average day so far? At peak in NYC? Trying to help RT and admin assess and order appropriate inventory prior to our surge in DC area…
Stay safe and sane,
Matt
I have tried the non nasal cannula set up with BVM and PEEP valve on the exhaust port of BVM. I placed it on myself with 15-20 l/min flow through the BVM and 4 to 6 l/min for PEEP valve. With PEEP at 5 very hard to exhale and my work of breathing went up. With each exhalation had mask leak due to increased pressure in circuit. I could envision that this could make a pt in respiratory distress uncomfortable I tried a somewhat modified set up :using a CPAP bag/device used in one lung anesthesia.: -mask -viral filter -on… Read more »
For what it’s worth: Ask your hospital administration to buy oxilators and use them in lieu of BMV. This will eliminate the risk of type 2 mask leaks (leaks originating from airway obstruction and finding path of least resistance from face seal). Once that is done, you’ve got to deal with exposure from just the type 1 leak ( originating from face seal while the airway is open, without obstruction). I think, this may cut exposure from air coming out from patient’s oropharynx by 50% or more. That air is loaded with viruses and is going to fill that room.… Read more »
What if we don’t have a viral filter available? How will that change your recommendations?
Oxylator should not be used without a viral filter. It beats the purpose. Also it won’t work if PEEP is needed.
I’d like to solicit the opinions of Scott Weingart and James DuCanto on the matter.
Silly autocorrect
Occasional Intubator
all oxylators are now shipping with peep adaptors; i have had mine on full time for a decade. if you can’t get them—3d print em. simple piece of plastic
The BVM is a “Manual Resuscitator”, whereas the Oxylator is an “Automatic Resuscitator” that can perform the functions of the manual resuscitator while controlling for inspiratory flow (fixed at 30 lpm), pressure (fixed at the pressure release setting) and tidal volume (fixed by the pressure release setting). It functions through mask (allowing two handed technique for improved seal and airway maneuvers to open the airway such as a jaw thrust), SGA/EGD as well as tracheal tubes, and can serve as an automated ventilation device during initial resus as well as for transport, should the need arise. While waiting for a… Read more »
Health hazards from the above videos: 1. NIPPV masks have built in leak ports on the front of masks. 2. Self inflating ambu bags do not provide free flow oxygen, you have to squeeze the bag to deliver oxygen. Flow inflating bags, or anesthesia bags do provide free flow oxygen. 3. In the amount of time it took to do all that, you could have easily intubated the pt and established a much safer situation for sll involved. 4. This is a colossal waste of resources in a time that we are burning through them at far too fast a… Read more »
What is the pressure level that opens up the leak ports? Please put together a pre-oxygenation system and put it on the show. While at it please put together also a system on how to oxygenate/ventilate with no or minimal baging, with no or minimal exposure. For the larger audience there are serious management issues here. From the exposure risk perspective: Should we bag at all, if we can’t properly oxygenate? Should we skip baging altogether and go straight to LMA, if O2 is going down? Should we access front of neck, if LMA is not going in easily? Or… Read more »
Stacey, I appreciate you taking the time to comment. Unfortunately, pretty much every comment you made is either factually incorrect or misguided. 1. There are no leak ports in our NIPPV masks–if yours do, then you probably should not be using them 2. Self-inflating bags do indeed ALL (yep, every single one ever made in the past 30 years) provide oxygen to a spontaneously breathing patient so long as you have or have created a one way valve at the exhalation port. 3. The only resource “wasted” is the NIPPV mask. Everything else is part of our vent circuit. If… Read more »
Scott, I would like to apologize for this Respiratory Therapist naive comments. I appreciate your ingenuity & I would like to offer you some RT “secrets” google Vortran ventilators.
thanks, Carrie! Have you liked the vortrans? When I played with ours, they seem pretty dismal. I need titrated PEEP, which it doesn’t have and I can’t seem to get any play on the RR dial. It is either superfast or nothing.
With Vortran ur PEEP is intrinsic and I used them for swine flu- better than bagging ur mom. I will post my video for u tomorrow. We’re all in this together
So 48 yo arrest en route suspected Covid .
I-Gel placed by EMS.
Poncho placed over patient in Negative pressure resusc room
VFib
Leave I-Gel in under Poncho pending ROSC or place ETT under poncho to have secure airway. But your removing the I-Gel, pausing compressions etc.
I’m just trying to think about what exposes the team more .
Thanks
igel
leave room
tell them to call you back when theres rosc
Hi
at the end of pre ox as soon as the mask comes off, all that PEEP in the lung, means the lung will deflate and you will get a shower or aerosolised virus as you put in the scope?
whatever apneic lung pressure is there is markedly less than that patients normal exhalation. There is no marked increased pressure in the lungs from a PEEP of 10 cm H20. It is a tiny exhalation with no pressure behind it. but if you are still worried, just take off the supplemental O2, either from the ETCO2 port or the Nasal cannula when you are ready to intubate–but honestly, where you will get totally burned is if you decide to preox with a ventilator. then when you remove the mask, extremely high-flow gas will push through the mask as you are… Read more »
Hey Scott, Do you have to disconnect the vent on the prox end of the filter before removing the face mask (as per Triple C)? As long as you are preoxygenating using the vent without any pressure support, could you not alternatively simply dial the PEEP down to zero before you remove the facemask? I worry about disconnecting the vent just proximal to the viral filter as that introduces a risk of accidentally disconnecting the viral filter. It also means you have to add steps to reconnect the vent if you need to reoxygenate and post intubation. Could you comment… Read more »
worried that back-up rate will kick in and blow covid all over through the mask. if you don’t want to disconnect prox to viral filter, pull of insp limb at the vent
Good point Scott. I now think that given the required modifications for using the ventilator for preoxygenation to improve staff safety that it both increases cognitive load and reduces some of the benefits of using the ventilator. Consequently I think for the vast majority of providers it would probably be best to avoid its use in preox for COVID-19 patients. Have explained my reasoning here in the addendum at the end.
https://www.edguidelines.com/vapox-protocol/
pressure support won;t help you for reox, pt is apneic. need a mandatory mode if you are going to use it for reox
What about pressure support with a mandatory rate? That was the initial VAPOX design.
yeah, sure
Hi
do you also use O2matic in then treatment of covid-19 patients ? im not related to that company but heard of good recent test results (Ultimo March 2020)
Two comments from Norway here, one on CPR and one on elderly patients from nursing homes; – CPR: At my hospital we’re very clear that we must donn full PPE before entering the room. No fire fighter would ever run into a burning house without proper gear, and neither should we. We have also said that in-hospital cardiac arrests get compressions only until the airway is secured (viral filter and all). Also, manual compressions are also only to be done until LUCAS compression machine can be established. Earlier the code blue team could call for the LUCAS if needed (since… Read more »
agree with all!
[…] [15] Weingart COVID Airway […]
Great post, thanks for all the hard work. Looking for some clarification – We’ve been advised to avoid NIPPV due to risk of aerosol generation. Given that you’re generating the same pressures, is CPAP via BVM+PEEP Valve+NC any different?
in disconnects, the set-up above would be markedly less dangerous (only 4-6 lpm of flow to the room)
in normal operation–probably similar, which is markedly safe. Problem is all studies were on open circuit cpap (as in a open valve leaking all over the environment. I have not seen anything on closed circuit cpap
Great stuff.
I would be cautious with the clamping the tube unless they are fully paralyzed due to concern for negative pressure pulmonary edema.
Also- more secretions with ketamine, consider giving glyco early on regardless of induction agent.
I hear ya re clamping, but there is no choice
Well, if you have a viral filter on the end of your ETT it should be sufficient.
Josh,
Please reread the section above or watch the video
We started using this
https://flussobypass.com/how-to-use/
If done correctly no break in circuit and no loss of pressure
Clamping ETT is a deviation from normal practice and makes processes around ETT/vent circuot management more complex. The more complex a system, the more prone for failure (both human and technical).
In fact, clamping may represent a ‘solution’ for a problem that doesn’t exist in the first place. I am not aware of any robust evidence that HCWs contracted covid19 when wearing appropriate PPE and which is caused by aerosilization.
Yes, Christian, you are absolutely right, I have no robust evidence published on the COVID19 pandemic showing HCP infection from unclamped ETTs.
Is it not common practice to clamp the ETT on ARDS patients with High PEEP when disconnecting the circuit to maintain recruitment? (i.e to switch ventilators, bag, etc). In the transport environment it has been a norm for some time and doesn’t seem to be an issue. Guarded ECMO clamps work well.
yes, we clamp for any PEEP>10
Good day I am an anesthesiologist involved in icu setup and care for covid19 patients.
I would like to know if you have a specific procedure for an accidental circuit disconnect in the icu?
Johannes van Niekerk
Anaesthetist
University of the Free State
South Africa
Run to the vent and pull inspiratory limb. Honestly, in this situation it is unlikely the bandwidth will be there to figure out which is which, so pull both limbs off the vent.
Then reconnect, then put the vent limbs back on the vent.
This is only for a disconnect distal to the viral filter.
Hi Scott, Thank you for all of this. Would suggest PAPR and N95 the combo is multiplicative protection plus PAPR that loses power is less protective than an N95 alone. Prior SARS outbreaks demonstrated HCW infection in those wearing N95/goggle/gown and gloves during aerosol-generating procedures. Happy to share references
This set up already is available with a boussignac CPAP. Quick, easy and cheap!
Our service and hospital has been having a lot of conversation about using a BVM. Our BVM looks to be the same as yours with an included bacterial/viral expiratory filter (between the bag and the PEEP in the videos). We reached out to the manufacturer and they responded: “the filter included in the AF5140MB Resuscitator kit is 99.99% effective at filtering bacteria/virus including COVID-19 (Coronavirus).” Is there a reason that you are recommending a filter placed between the mask and the BVM? Difference in filter quality, fear of accidental disconnection, or simply two is better than one? We do have… Read more »
it is not 2 better than onethe viral filters included in the bag do not function while wetand lose efficiency with pt secretionsplus you need a viral filter between ETT and vent once intubatedif you have peep valves that fit on the naked expiration port then just move the bag’s viral filter to the BVM stem and then you don’t need to waste a 2nd filterour peep valves only fit with that filter in place
Great points, I really appreciate your response and we all enjoy and appreciate all of the emcrit content you share with us!
Thanks for this amazing information
Your setup for BiPAP is very helpful. In our ED we use a V60 for BiPAP so we have a single limb and a passive exhalation port. Would we be able to place a filter between the mask the the circuit (proximal to the exhalation port) to achieve a safe BiPAP setup? I see in your setup above you have a filter in this position, but also where the exhalation limb comes into the unit so it appears double filtered. Would this be a good use for a HEPA filter if there is only one opportunity to filter?
Scott, today I built a similar system but used a flow inflating bag, H system, with PEEP, minimal resistance, pressure line for measuring actual PIP/PEEP, and lower oxygen flowrates. Email me and i can send you my pictures and Vortran video, since i can’t post here.
Hi Scott, In Australia we haven’t hit anything much in terms of ICU needs – 4700 positive results and ~20 in ICU today Wed 1st April. There’s been a certain amount of paranoia [ understandably ] about BiPAP / high flow of > 30-40 liters / min and some are discussing that if the person needs > 6 liters / min on a standard Hudson mask, they should be intubated. This is going to use a lot of resources, needlessly in my eyes. Do you have any figures on what % of pts have oxygen requirements of 30% / 40%… Read more »
Take a look at the infographic in this Protected Code Blue google doc and details. The key is early intubation so you don’t have to pre-oxygenate. https://docs.google.com/document/d/1a6mXai4RqQ7BexbdK6AFoSvzxxUjvsT4 All 02 delivered via NP should have a surgical mask on it and there are exhalation filters that can be put on face masks: look up Hi0x masks. The bigger risk coming up is HFNC and how to contain the aerosols (hoods, suction on a FM over top? Tents?) What is the right PPE for staff treating these patient, time limit in the room to reduce exposure etc. We know the PPE the… Read more »
Dr. Jesse Glueck, EM/PEM FL. One of our amazing RTs suggested that an anasthesia bag hooked up to O2 with a viral filter between the mask and the bag would.provide the same type of preoxygenation solution without all the extra bits needed if using the Ambu bag set up. I’m also assuming since this is a closed system some of the exhaled CO2 is escaping around the mask (not filtered) but all the filtered exhaled CO2 is staying in the system and then patient reinspiring it. Dont we then risk making them more and more hypercapneic prior to paralyzing them?
that’s not how BVMs work at all
Hi, Scott. If RT has verified that the hospital lacks the blue adapters for the NIPPV masks (i.e., the NIPPV masks are not unvented), is there a fix for that (e.g., tape over the holes in the clear adapter that attaches to the mask, or some other kind of airtight connection that can be made with the mask)?
Maybe taping pieces of N95 mask around the holes?
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Why are booties a big risk? I have my ideas but I’d like to hear yours
that is the CDC recommendations. So I am only guessing, but in my experience it is nearly impossible to get the damn things off of my shoes without touching everywhere and occ. stumbling
think it would be better to just take the shoes off and then remove them.
was tempted to intubate barefoot and then just clean my feet. But there is only so far one can go before they call a psych consult.
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good talk
please let me suggest
use glycopyrrolate to pretreat to dry mouth
use deep anesthesia to decrease secretion forming
use narcotics to suppress cough especially for extubation
use ballottement on suprasternal notch and pinch the pilot balloon partly to feel the et cuff being pushed and adjust accordingly for tube placement
Hey EMCRIT fam- working in busy NYC ER and in one of our holding areas was a Covid patient (obviously), currently on NRB, desperately needing CPAP. Duh, no machines available. Remembered seeing this post and ran over to the stock, room, made it in about 5 minutes and put in on the patient with the PEEP valve and after about half hour he had significantly decreased work of breathing, no changes in mentation, O2 sat always close to normal. This morning read his progress note: “Breathing comfortably and in no signs of respiratory distress.” This post quite “literally” saved this… Read more »
What are your thoughts on the plexi-glass/acrylic boxes being used for protection when intubating? Worth it or just another obstacle hindering first pass success? If you could design something similar, what would your “must haves” be?
think they are a hindrance if you have good ppe, would use them if i did not have some form of full face hood
Is there any application suitable for the pre hospital setting? Specifically CPAP. Our CPAP devices do not require a vent but I’m still doubtful that they may be safe to use in the pre hospital setting. Any advice?
how about an off the shelf CPAP system with an off the shelf O2 generator providing O2 to the CPAP system. can be put together in 5 minutes with a little duct tape. can provide monitoring and controls using a downloadable app.
the whole system would cost less than $1k to 2k retail.
suitable for non critical patients, allowing actual ventilators to be used for those with critical need
example diagram
https://twitter.com/MyFight4MyPower/status/1247350378602967040/photo/1