Intubating Patients with COVID

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Harman Gill
I am a proud Indian by ethnicity and Sikh by religion who lives in the lovely upper valley here in New Hampshire. I love to host, cook and engage in health conversations and loud debates where decibels can be raised but respect is never lost! Talk to you soon!

COVID-19 has changed many things in our lives at work and procedures are no different!  As frontline providers, it is not only imperative to efficiently execute procedures but to also do them safely. This procedural mini-series will review essential tips for the proceduralist and crucial system based improvements to keep you safe, your team efficient, and of course your procedures successful!

COVID-19 has changed many things in our lives at work and procedures are no different!  As frontline providers, it is not only imperative to efficiently execute procedures but to also do them safely. This procedural mini-series will review essential tips for the proceduralist and crucial system based improvements to keep you safe, your team efficient, and of course your procedures successful!

Let’s start with airway management in the COVID-19 era.  I call them the five P’s or pearls of the COVID airway…

  • Prepare
    • Endotracheal intubation is an aerosol-generating procedure and should only be done in dedicated negative pressures rooms with full PPE
    • Whether it is an airway bag or pack, make one for your team and leave your fancy airway towers outside. Make the contents single-use only as everything that enters the room, is thereafter considered contaminated.
    • Consider making COVID specific order sets in your EMR to make you efficient and your team effective! Think of NOT ONLY what you need but also your nurses & RT’s.
  • Providers
    • Whether you have a dedicated COVID airway team or you are doing your own airways there needs to be a clear person in charge!
    • Have a discussion about how that person in charge may change if you hit a surge in volume and acuity
    • Regardless the key here is: most EXPERIENCED AIRWAY operator should be intubating!
  • Pre-Ox
    • Prefer high FiO2 and flow-based devices like HFNC. Place level 2 mask on the patient too!
    • If using positive pressure devices like NIV, do it on the vent with an HME filter
    • Avoid the use of a BVM. If you must, then use a two-hand seal, with an HME filter in a negative pressure room. Want to know more, see attached video and pictures for BVM setup
  • Perform
    • RSI is preferred mode as paralytics decrease the risk of aerosolization during laryngoscopy
    • Set yourself up for success – use VL! Increases distance between aerosolized particles & you.
    • Use a checklist to designate specific tasks for each team member. Be specific and review as a team and we recommend a team huddle before entering the room.
    • Airway operators: in charge of airway equipment and selection of induction medications.
    • RT’s: in charge of pre-oxygenation devices, ET tubes & vent.
    • Nurses/pharmacists: in charge of weight-based medications. Remember actual body weight! This includes Induction agents, paralytics, vasopressors & post-intubation analog-sedation. Check out the sample checklist in the video!
  • Practice
    • IN-SITU SIMULATION! Intubating in a PAPR is quite a challenge. It’s really hard for you to hear your nurse, your monitor, and vice versa for the rest of your team. Closed-loop communication is paramount, practice often and figure out where your own internal system breaks down and where it rocks!

Ultimately, your training, your troubleshooting skills, and your dedication will see you through.  Want to know more, watch the attached video, or just ask me!

Till next time – FORCA!

Figure 1: The 5P’s of the COVID Airway

The Debrief

  • The most experienced operator attempts airway in a negative pressure room with appropriate PPE
  • Develop your own protocol for airway bags, teams, and processes in a surge situation and a routine situation.
  • 2 hand BVM technique, HFNC with a level 2 surgical mask is preferred mode for pre-ox, HME filter on BVM, NIV, or vent always and VL first with complete RSI.
  • Practice, practice, practice. In-situ simulations rock with your entire team

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