covid-19 airway management principles · covid-19 airway management: sas • safe – for staff and...

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COVID-19 Airway management principles

COVID-19 airway management: SAS • Safe – for staff and patient • Accurate – avoiding unreliable, unfamiliar or repeated techniques • Swift – timely, without rush or delay


Summary for emergency tracheal intubation of COVID 19 patient - Tracheal intubation of the patient with COVID-19 is a high-risk procedure for staff, irrespective of the clinical

severity of disease. - In severe COVID-19 it is 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. - Intubate 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. - videolaryngoscopy 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. - Avoid aerosol-generating procedure, 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-1 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 7.0-8.0 mm ID (females) or 8.0-9.0 mm ID (males) tracheal tube with a subglottic suction port. - Pass the cuff 1-2 cm below the cords to avoid bronchial placement. Confirming position is difficult wearing PPE. - Inflate the tracheal tube 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 tracheal 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. - If airway difficulty occurs the subsequent plan should be displayed in the room and communicated between shifts.


Figure 5. Checklists. (a) Adapted from [20] with permission (b) from [26] a


Figure 6. Cognitive aids for use when managing unexpected difficulty when intubating a patient with COVID-19. (a) and (b) Highly adapted from [20] with permission (c) from [27] with permission. a


b


c

Covid-19 ICU intubation Team Leader Command Sequence

OUTSIDE THE ROOMA: PREPARATION

B: PPE

INSIDE THE ROOMC: ROOM LAYOUT CHECK

D: PRE-INTUBATION CHECK

Tick when complete

Clarify first names and roles, Distribute Action Cards to the team.Check equipment outside the room:

- Airway equipment set out including Glidescope- Drugs

Review patient clinical information

Provide scripted pre-brief to whole team:- We’re going to intubate a patient with suspected COVID19- Our priority is staff safety- We will be following a protocolised intubation process- Myself, the airway doctor, and the airway nurse will go in at this stage- The Nurse Team Leader will work from the ante-room & the Clean Runner will

remain outside- Look out for each other’s safety and communicate clearly- Are there any questions?

Tick when complete

Intubation team to don PPE and cross check

Tick when complete

360 degrees of access around bed

Airway kit and nurse on patient’s RIGHT

Orange bin bag/box to LEFT of patient’s head

Team leader foot of bed drugs on table

Ventilator is in reach of team leader, settings applied and in standby mode

Tick when complete

Patient on NRBM @ 15L/min

E: RSI CHECKLIST – SEE SEPARATE SHEET

F: INTUBATION

Airway Team assembles equipment as per ‘Silhouette Placemat’

Cut NRBM straps both sides and hold mask on face

Change oxygen supply on wall to BVM

Remove NRBM - discard in white bin carefully

Apply BVM with two handed seal

Ask anteroom nurse TL to ‘start timer for 3 minutes’

Tick when complete

RSI checklist complete

Tick when complete

3 Minutes up

Inject induction drugs plus Sux/Roc

Fasciculations present, then ceased

Turn off wall oxygen

Remove BVM (chin end off first) & place in blue bag carefully

Intubate (anaesthetist verbalise view) with styletted tube or over bougie

TL to administer rocuronium/atracurium

Remove stylet or bougie slowly and vertically through gauze and dispose in bin carefully

Inflate tracheal tube cuff

Connect ventilator circuit and ETCO2 and closed suction

G: POST INTUBATION CARE

Start ventilator

ETCO2 confirmed

Secure tube

Tick when complete

Adjust ventilator settings as required

Give further fentanyl / midazolam as required

Insert NGT and connect to closed drainage system

Nursing Team Leader to remove clean equipment from anteroom prior to others doffing

Instruct any other staff entering the room to wear airborne precautions in the post-intubation period

Conduct debrief

1. Commence Preoxygenation ✓

Mask - Filter - Catheter Mount - BVM with PEEP Valve. Connectors secure and reservoir Full

Two handed technique

2. Airway Brief ✓

Plan A - Bougie / Stylet and Glidescope blade choice confirmed No cricoid force,

Consider Head elevation / External laryngeal manipulation prior to Plan B

Plan B - iGel Can’t Intubate Can’t Oxygenate - Front of Neck Access from patient’s LEFT with head extended. NO iGel ventilation

Talk through stylet / bougie handling and disposal

3. Patient preparation ✓

Position - head up 30 degrees and ear to sternal notch alignment

Intravenous / osseous access x 2

Fluid connected on blood pump giving set, runs easily.

BP cuff on contralateral arm, 1 minute cycles

ECG monitoring

SpO2

Haemodynamics optimised (consider peripheral noradrenaline)

Blue bag secured to patient’s left

4. Airway equipment ✓Suction checked

Direct Laryngoscope checked

Glidecope, AC power confirmed, on & checked

Two tracheal tubes

Stylet in Tube

Bougie

Gauze

Syringe

Tube tie

iGel

Cricothyrotomy set

Two portable oxygen cylinders, ‘in the green’

Oxylog connected to one cylinder

Oxylog settings: FiO2 1.0, PEEP 10, Pmax 45, VT and freq set

Vent Circuit, closed suction system, HME Filter, EtCO2 and block

All connectors checked and secure; all ports closed

Gastric tube, tape, drainage bag

5. Drugs ✓Induction drugs:Thiopentone 500mg Propofol 200mg Ketamine 200mg, Sux 200mg Roc 100mg

Post intubation drugs: Propofol 50ml Midazolam 10mg, Rocuronium 100mg

Vasopressors: Metaraminol 10mg/20ml and Adrenaline 1mg/10mls

“Checks complete. Anaesthetising now please note the time”

Adult COVID-19 RSI Checklist

COVID-19 AIRWAY DOCTOR

GoalsMaintain own and team safety. Minimise exposure and aeorsolisation duringlaryngoscopy; and avoid episodes of aninadvertant open circuit.Safe, rapid intubation wth minimal desaturation

PrepareConfirm airway plan, equipment and ventilatorsettings while outside roomIdentify preferred VL blade - ensure spares movedto anteroomDon intubation-team PPE with buddy checkPerform airway assessmentOpen and secure blue bag to left of patient's headOptimise patient position. Ensure additionalblankets available.Complete Team RSI checklist and confirm ready

Remove Oxygen mask (Hudson or NRB)

Maintain two handed BVM mask seal for at least3 minutes during pre-oxygenation and untilparalyis completedEnsure gas flow is off before removing maskfrom patient's face to blue bag Perform videolaryngoscopy. Pass ETT over stylet Ensure cuff up before attaching ventilator andconfirming by EtCO2Rescue device is an iGel.If proceeding to FONA, ensure gas flow off priorto incisionInsert gastric tube, close and secure.

- airway nurse places directly in the bin

Post intubation - patient to ICU with Med TL and NTLRemain in room with airway nurse - decontaminate CMAC blade andensure sent to CSSD urgently.Decontaminate with buddy check

RSI

COVID-19 AIRWAY DOCTOR

COVID-19 AIRWAY NURSE

GoalsMaintain own and team safety. Support rapid intubation and oxygenation.Ensure minimal droplet spread and rapiddisposal of soiled equipment

Prepare

Prepare airway trolley and ensure eqpt presentEnsure spare CMAC blades are in anteroomTransfer box, suction and monitor with runner

Don PPEand buddycheckEnsure allconnectorsare secured

RSIComplete team RSI checklistMove oxygen mask directly to the bin. Set BVMoxygen flow to 6l/min and hold the BVM duringpreoxygenationTurn off gas flow prior to BVM mask removal onceparalysis completeCarefully remove bougie/stylet directly to bin throughgauze on instruction - CAUTION for splatter.Inflate cuff with 10ml air.On instruction connect ventilatorRescue device is an iGel.Secure tube once airway confirmed

Post intubation - patient to ICU with Med TL and NTLRemain in room with airway doctor - decontaminate Glidescope blade and ensure stylet sent to CSSD urgently.Decontaminate with buddy check

COVID-19 AIRWAY NURSE

COVID-19 TEAM LEADER - NURSING

PrepareReview drug plan with medical team leader andensure all necessary drugs present:

Thiopentone 500mg/20ml orPropofol 200mg/20ml or Ketamine 200mg /20ml Suxamethonium 200mg / 4ml Rocuronium 200mg / 20ml Midazolam 10mg / 10ml Metaraminol 10mg / 20ml Adrenaline 1mg / 10ml

Hartmanns or NaCl 0.9% 1000ml and pump set Ensure Nurse TL / MedTL/ Runner have radios / dectphones & know the numbersClear space in anteroom. Hold spare VL blades.

GoalsTeam safety - provide overwatch of team throughoutprocedure & maintain situational awarenessPass equipment as required to Medical Team LeaderGood communication with supporting teams

Actions

Continuously monitor team for PPE or patient

risks and inform medical team leader

Coordinate actions of runner, wardsman and

security.

Note paralytic time, and inform team leader

Pass equipment as required

Inform ICU NUM & Bed Mgr when intubation

complete and confirm ready for arrival

Take over care of the patient with the medical

team leader and transfer to ICU

Ensure decontamination of equipment after

handover

Lead team debrief

COVID-19 TEAM LEADER - NURSING

COVID-19 Medical Team Leader

GoalsEnsure team safetyOveral responsibility for the patient.Optimise physiologyMaintain a shared team mental modelMaintain stability following intubation, andtroubleshoot ventilation problems

PrepareReview patient assessment with intensiviston call.Consider special considerations, andinterventions required for haemodyamicoptimisationBrief team outside room - see briefing cardDon intubation team PPE and buddy checkAssess anatomy for front of neck access

ActionsRemain at foot of bed as much as possible.

Coordinate preintubation briefing - ensure

common understanding of COVID specific items.

Administer drugs and inform NTL of time

Support team model using the Command Actions

card.

Administer rocuronium and sedation following

succesful placement of ET

If rescue iGel not successful, perform front of neck

access

Direct post-intubation actions and complete pre-

departure checklist.

Transfer the patient to ICU with the nursing team

leader. Hand-over to Intensivist.

Support NTL to decontaminate equipment, doff

PPE with buddy check, and debrief

COVID-19 Medical Team Leader

COVID-19 Clean Runner

Goals

PrepareConfirm DECT phone numbers / radio channelReview plan with NTL and fetch necessaryequipment

ActionFetch drugs / eqpt as requiredCommunicate with other services as per NTLDocument actions at request of NTLCarry COVID airway transfer box ahead ofteam on transfer.Ensure clean modules removed from ICUmonitor prior to patient entry

Ensure that necessary equipment is provided tosupport safe, rapid intubation.Ensure safety of staff not involved in theprocedure by maintaining exclusion around theroomSupport accurate documentation of the procedure

COVID-19 Porter 1

GoalsSupport safe transfer of patient to ICUEnsure patients and staff cannot accesscontaminated spaces prior to deep clean

PrepareAcquire the master key for lift control.Consider the route to ICU, hazards and areasof possible public contact

Remain clean - do not touch the patient orbedAccompany team and ensure a clear path tolift. Set lift to "Priority"After lift use, lock lift and mark DO NOT USE.Inform cleaning staff and ensure no use ofthe lift until cleaning complete.

Actions

COVID-19 Porter 2

Prepare

Accompany team to ICUEnsure the bed does not contact surfacesDo not enter ICU room until instructedSupport the clinical team with movement ofpatient and equipmentAsssist the clinical team withdecontamination of bed and equipment.Doff PPE with support from clinical team

GoalsMaintain your own and team safetyMove the patient safely to ICU

Don PPE and buddy checkGown, gloves, mask, eye protection,booties

Actions

covid-19 airway management principles · covid-19 airway management: sas • safe – for staff and...

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