There’s more to the safe intubation of a patient with suspected COVID19 than PPE. It requires, preparation. planning, team-based training and a thoughtful workflow to minimize exposure.
The lessons learned to date from clinical experience with the intubation of suspected COVID19 patients? PPE is important but not the whole story. You need a protocol that offers additive layers of safety: preparation, planning, team-based training, and a workflow design that focuses on procedure safety by minimizing exposures is essential. Here are the highlights of ours. This protocol is based on experience at our institution, with hundreds of intubations performed at the peak of the outbreak in NYC.
The Decision to Intubate
COVID19 patients frequently present as dramatically hypoxic, but can often be stabilized with supplemental oxygen using NC/NRB/HFNC. Do not rush to intubate based on a number but consider the patient’s overall respiratory status:
- Mental status
- Work of breathing
- Respiratory rate
- Oxygen saturation
Patients with low oxygen saturations and elevated respiratory rates are often awake alert and without significant increased work of breathing or respiratory distress. If this is the case we recommend attempting a trial of oxygen supplementation by non-invasive means first.
If the patient cannot be stabilized by NC/NRB/HFNC then, proceed to ETI.
- Prior to intubation
- Discuss with patient and family if possible first
- Confirm goals of care and advanced directives.
- Need for intubation
- Need for central/arterial lines, foley, vasopressors
- Ensure you have next of kin contact information
Donning & Doffing PPE
Experience with donning and doffing PPE is essential.
- STOP! The first step to donning PPE? Hand Hygiene.
- Don PPE (contact, airborne, droplet precautions) outside of the patient’s room. This should include:
- Glove #1 under gown & Glove #2 over gown
- Fluid-proof (Blue) gown
- N95 mask vs PAPR (N95 less effective if facial hair)
- If available, hood covering entire head and face or bouffant cap
- If no hood: eye protection with face-fitting goggles, bouffant hat
- Welder’s shield
- Remember to leave all personal effects out of room (phone, ID, stethoscope, everything)
Intubation Team & Roles:
- Use only the required personnel needed to safely performing the procedure.
- Most experienced practitioner should perform the intubation
- Call respiratory therapy to bedside
- RN for assistance & medications
- All other team members should be outside the room but available to assist if needed.
Steps of Intubation
Pre-OX & Pre-intubation checklist:
- Advance planning and clear communication are paramount
- Ideally place the patient in a negative pressure room.
- If a negative room is not available, place the patient in a single room and close the door.
- If no rooms are available (e.g., ED), isolate the patient and ensure that other patients/HCW maintain > 6 feet (2 m) distance.
- Prepare medications and intubation equipment outside of the patient’s room
- Induction agent, Paralytic, Vasopressor, Flush syringes and a sedative for post intubation
- Have a dedicated provider outside of the room to hand additional equipment or medication as needed
- Have Respiratory Therapy to assist set up ventilator
- Make sure there is a HEPA filter on the expiratory limb of the ventilator; if not place HEPA filter between ETT and Y of the ventilator tubing
- Confirm ETCO2 waveform capnography is functional (if available); If colorimetry is used place EZCap after HEPA filter
- Ensure WORKING IV. (place IO if difficult to obtain & IV placement is causing delays in vital care)
- Prolonged pre-oxygenation required for more than 5 minutes: for example with 100% FiO2 non rebreather (caution: expiratory ports may aerosolize secretions)
- Place surgical mask over NRB mask
- Make sure all items are in the room before proceeding
- Working Suction
- Ventilator With Viral Filter
- BVM w/Viral Filter/PEEP valve
- 10cc syringe
- Video laryngoscope (preferably McGrath for easy cleaning)
- Tube securing device
- RSI medications
- Push dose pressors
- IV flushes
- IV fluids (running)
- Disposable stethoscope
Laryngoscopy & Tube Delivery
- Most experienced provider should intubate
- RSI is method of choice with high dose paralytic of choice to reduce aerosolization of viral particles from patient.
- If your need to use bag-mask ventilation, use 2 hands to provide good seal, use HEPA filter between mask and Ambu bag, deliver small tidal volume
- Use video-laryngoscopy preferred to increase the distance (e.g., McGrath is preferred for ease of decontamination, however use of Glidescope with standard or hyper-angulated blade is fine but needs a decontamination protocol after use)
- Inflate cuff immediately after intubation
- Immediately connect the patient’s ETT to the ventilator. Do not use BVM
- Secure the tube with ETT holder or tape
- Take off top layer of gloves after intubation and prior to touching other equipment
- Careful – do not contaminate yourself during this process
- Raise Head of bed 30Deg
- Use ARDSnet Protocol
- Perform Plateau Pressure <30cmH20
- Goal 02 sat 88%-95% or Pa02 55-80%
- Ensure patient is fully sedated and not pulling on vent
- Initial Observation Period
- Observe patient vital signs
- Expect a delay and minimal improvement of 02 sat in COVID19 patients
- Avoid the initial instinct to BVM the patient
- Avoid any disconnection of the circuit, however, if you must, put the ventilator on stand-by, NOT simply disconnecting as it may disperse particles
- Use disposable stethoscope to examine the patient
- RT assistance with ventilator and help with applying ETT holder
- If you need to disconnect the patient from the ventilator, put it in standby first
- Dispose used and all disposable items that were brought into the room in trash cans in patient’s room
- Video Laryngoscopy ideal method of intubation
- McGrath: remove battery and clean all surface areas and then place into the specimen bag
- McGrath preferred for ease of decontamination
- If Glidescope is used all surfaces must be completely wiped clean with purple wipes immediately after the procedure just outside the room.
- Doffing is a high risk moment for possible self-contamination. Follow meticulous removal of PPE checklist. Consider use of “spotter” to assist providers with PPE removal.
- Ideally doffing should occur in an anteroom (can remove all pieces including N95, and wash hands).
- If anteroom is not present, then doff in patient’s room (at least 6 feet away from the patient), except for the N95 mask, which is removed outside of the room.
- Hand hygiene.
- Wash hands or Purell, Apply new non-sterile gloves and clean McGrath or glidescope with Purple wipes, allow 2 minute dry time
Listen to my conversation with Ralph Slepian MD: & discover some of the lessons learned from his COVID19 intubation team.
- Wear full PPE (airborne, droplet, contact protection) for an aerosolizing procedure
- Use only essential team (usually 3 people: Intubator, Assistant, Respiratory)
- Take only what you need with you into the room, other items should be safely passed to team.
- Use RSI with high dose paralytic of choice
- Place immediately on ventilator with viral filter
- Doffing is a high risk period for possible self-contamination
COVID19 AIRWAY LESSON REVIEW CARDS