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Intubation Guidelines Summary

1) Early intubation of COVID-19 patients has been suggested to better control ventilation and reduce risk of transmission compared to prolonged noninvasive ventilation. 2) Full PPE including N95 masks and preferably PAPRs should be used for intubation. Intubation should be performed using video laryngoscopy to increase distance between providers and patients. 3) Ventilation should be initiated with tidal volumes of 6 cc/kg ideal body weight, respiratory rates of 23-24, and potentially high levels of PEEP given the expected difficult ventilation with COVID-19 patients.

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86 views

Intubation Guidelines Summary

1) Early intubation of COVID-19 patients has been suggested to better control ventilation and reduce risk of transmission compared to prolonged noninvasive ventilation. 2) Full PPE including N95 masks and preferably PAPRs should be used for intubation. Intubation should be performed using video laryngoscopy to increase distance between providers and patients. 3) Ventilation should be initiated with tidal volumes of 6 cc/kg ideal body weight, respiratory rates of 23-24, and potentially high levels of PEEP given the expected difficult ventilation with COVID-19 patients.

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riccardo
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UMMC AED SUMMARY MARCH 12, 2020

Intubation and COVID-19


Preliminary Guidelines (Version 1) - Likely to Evolve

Avoid BiPAP
High risk of
aerosolization.
Recommend
against use.

High Infectious Risk to ED Staff


HFNC w/ Caution
These are preliminary guidelines to provide optimal care to
May still increase
patients while protecting our staff. Please read carefully. aerosolization. Limit
**Early intubation of COVID-19 patients has been suggested** If a patient requires to 15-30 L/min
intubation, please consider the following modifications. It is reasonable to presumptively
approach a severe respiratory distress BIBA as a potential PUI. Full details are included on
the second page (put together by our Capital Region colleagues).

1 2 3
Only Video
LIMIT STAFF USE FULL PPE MODIFY VENT Laryngoscopy
1 nurse, 1 RT Ideally use negative TV of 6 cc/kg Increase distance
pressure room between doc and
Ideally 1 doc Higher RR (23-24), may pt. Wipe down after
PAPR preferred > N95 require higher PEEP

1
Capital Region COVID-19 Intubation Guidelines 3/11/20
Airway and ventilatory management of COVID-19 patients has been proven to be difficult and a time of high
infectious risk to Health Care Workers (HCW). These guidelines have been developed in an effort to provide
optimal care to patients while protecting our staff. When considering ventilatory management, consider the
following:
• Noninvasive support: Traditional Noninvasive Ventilatory options are BiPAP and High-flow nasal
cannula (HFNC)
o BiPAP – High risk of aerosolization, performed worse than HFNC in ARDS in FLORALI trial.
Recommend to avoid use in these patients.
o HFNC – Has performed better in COVID-19 patients in early trials, may still increase
aerosolization
§ Suggestion to use rates of 15-30 liters/minute to reduce risk to HCW
• Early intubation of COVID-19 patients has been suggested, rather than prolonged NIPPV. Expected
clinical course of the severely ill suggests this as a viable therapy and affords several benefits:
o Earlier control of ventilatory strategy
o Reduced risk of transmission post procedure
o Crash intubation has high risk of aerosolization and HCW infection

Once the decision has been made to intubate a patient with suspected or known COVID-19, the following
procedure should be followed:
• Patient should be located in a Negative Pressure (NP) space for procedure, whenever possible. If the
current spaces are located, efforts should be made to move the patient briefly into the location for
the procedure – once intubated, patient will be on a closed circuit and can be moved back to droplet
precautions if no NP space available.
• Ensure all appropriate airway equipment and meds are prepared prior to entering room. Team
should be minimized to essential personnel: 1 nurse, 1 RT and 1 physician (most experienced airway
physician)
• Team should be in full PPE – at the very least, N95 mask with full overlying face shield, gown and
gloves. Strongly consider PAPRs for the procedure.
• Avoid the need to bag patient peri-intubation. Preoxygenate as well as possible – suggestions note
at least 5 minutes on 100%FiO2 by BVM. BVM should have viral filter attached – respiratory has
acquired a supply and will create COVID BVM kits for all relevant locations. PEEP valve should be
attached to prevent derecruitment.
• All intubations will be performed using Video Laryngoscopy to increase distance between physician
and patient and ensure first pass success. Immediately after stylet removal, viral filter will be
replaced between ETT and BVM and cuff will be inflated. VL camera will be wiped down and
replaced. Consider use of ultrasound sheath for additional protection, supply permitting.
• Consider alternate methods of ETT confirmation to avoid stethoscope contamination / utilization of
disposable materials. Qualitative end tidal CO2, capnography, etc.
• All PPE materials should be doffed and disposed of in room. N95 masks are NOT to be reused after
this procedure, despite face shield.
• Patient should be started on Tidal Volume of 6 cc/kg per ARDSnet. Respiratory therapy will ensure
Ideal Body Weight has been calculated. Patients should be started at a relatively high respiratory
rate (23-24) initially and may require high levels of PEEP.

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