Tracheal intubation in COVID-19: Multisociety guidance released
The predominant COVID-19 illness is viral pneumonia. Airway interventions are mainly required for tracheal intubation and establishing controlled ventilation.
The faculty of Intensive care medicine, Intensive care society, Association of Anaesthetists and Royal College of Anaesthetists have brought out Airway management Guidance in Covid 19 patients.
The guidance points out that Procedures during initial airway management and in intensive care unit (ICU) may generate aerosols which will increase the risk of transmission. However, as the epidemic increases there will be many patients in the community with COVID-19 who are asymptomatic or have mild disease. These patients may present for emergency surgery for unrelated conditions.
Summary for emergency tracheal intubation of COVID-19 patient
- Tracheal intubation of the patient with COVID-19 a high-risk procedure for staff, irrespective of the clinical severity of the disease.
- In severe COVID-19 is it also a high-risk procedure for the patient
- Limit staff present at tracheal intubation: one intubator, one assistant and one to administer drugs/monitor patient.
- Create a COVID-19 tracheal intubation trolley that can be used in ICU or elsewhere.
- PPE is effective and must be worn. Wear full PPE at all times. Consider double gloving. Defog goggles and/or eye wear if possible. Touch as little as possible in the room to avoid fomites.
- Intubation should take place in a negative pressure room with >12 air changes per minute whenever possible.
- Everyone should know the plan before entering the room – use a checklist to achieve this.
- Plan how to communicate before entering the room
- The algorithm/cognitive aid you plan to use should be displayed in or taken into the room.
- All preparations of airway equipment and drugs that can take place outside the room should do.
- Use a kit mat if available.
- The best-skilled airway manager present should manage the airway to maximise the first pass success.
- Focus on safety, promptness and reliability. Aim to succeed at the first attempt because multiple attempts increase risk to sick patients and staff. Do not rush but make each attempt the best it can be.
- Use reliable techniques that work including when difficulty is encountered. The chosen technique may differ according to local practices and equipment. With prior training and availability this is likely to include:preoxygenation with a well-fitting mask and a Mapleson C ('Waters') or anaesthetic circuit, for 3-5 minutes.video laryngoscopy for tracheal intubation;2-person, 2-handed mask ventilation with a VE-grip to improve seal;a second-generation supraglottic airway device (SAD) for airway rescue, also to improve seal.
- Place an HME filter between the catheter mount and the circuit at all times. Keep it dry to avoid blocking.
- Use of aerosol-generating procedures should be avoided, including high-flow nasal oxygen, non-invasive ventilation, bronchoscopy and tracheal suction unless an in-line suction system is in place.
- Full monitoring, including working continuous waveform capnography before, during and after tracheal intubation.
- Use RSI with cricoid force where a trained assistant can apply it. Take it off if it causes difficulty.
- To avoid cardiovascular collapse use ketamine 1-2 mg.kg-1, rocuronium 1.2 mg/kg or suxamethonium 1.5 mg.kg-1.
- Have a vasopressor for bolus or infusion immediately available for managing hypotension.
- Ensure full neuromuscular blockade before attempting tracheal intubation.
- Avoid face mask ventilation unless needed and use a 2- person low flow, low pressure technique if needed.
- Intubate with a 7.5-8.0 mm ID (females) or 8.0-8.5 mm ID (males) tracheal tube.
- Pass the cuff 1-2 cm below the cords to avoid bronchial placement. Confirming position is difficult wearing PPE.
- Inflate the tracheal cuff to seal the airway before starting ventilation. Note and record depth.
- Confirm tracheal intubation with continuous waveform capnography – which is present even during cardiac arrest.
- Use a standard failed tracheal intubation algorithm with a cognitive aid if difficulty arises.
- Communicate clearly: simple instructions, closed-loop communication (repeat instructions back), adequate volume without shouting
- Place a nasogastric tube after intubation is completed and ventilation established safely.
- If COVID-19 status not already confirmed take a deep tracheal aspirate for virology using closed suction.
- Discard disposable equipment safely after use. Decontaminate reusable equipment fully and according to manufacturer's instructions.
- After leaving the room ensure doffing of PPE is meticulous.
- Clean room 20 minutes after tracheal intubation (or last aerosol-generating procedure).
- A visual record of tracheal intubation should be prominently visible on the patient's room.
- After airway difficulty, the difficult airway plan should be displayed in the room and communicated between shifts.
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