COVID Airway Management Thoughts

This page will serve as the repository of COVID19 airway management thoughts and recommendations. Each time I post something new, it will exist as a separate post for a week and then be merged into this page.

For the Most Comprehensive Info on COVID19, go to Josh's IBCC Chapter

We are at Risk

Inutbations

* El-Boghdadly et al. estimated around 1 in 10 intubations would lead to infection [10.1111/anae.15170]

Non-Rebreather Masks

* First10EM

PPE - What to Wear

* N95 (add a PAPR if available to the N95)

* Surgical Mask over N95

* Goggles that surround eyes with facial contact, face shield, or full joint-replacement-hood with visor (full face coverage desperately preferred)

* Bunny suit, preferably with hood or disposable fluid-proof gown

* Something to cover your neck if not in hood

* If no hooded suit available, disposable cap

* 2 pairs gloves, 1 under sleeves of bunny suit or gown and 1 over, under-layer gloves would ideally be long cuffed

* Booties are a big doffing risk, so wear shoes you can disinfect

Preoxygenation

All of this is based on no evidence (there are no evidence-based strategies out there)

Non-Rebreather

This has been the most recommended strategy in articles/write-ups, but in my mind, it may be the worst of the viable options. To get a decent fiO2, you will need to crank it up to flush rate and I am not sure what effect that will have on the patient’s exhalations becoming aerosolized.

NIPPV

This has been panned for potential to increase risk to providers—however, that is predicated on passive exhalation systems (i.e. vents exhalation goes to the environment and has only 1 tube). However, a 2-tube system is a closed circuit. With the addition of 2 viral filters, this may be acceptable in a negative pressure room. It can also be left on during the apneic period with a jaw thrust. Place on CPAP/PSV, leave the PSV at 0, dial up PEEP only if patient’s saturations do not come up with 100% fiO2.

Critical Note: If you use the vent for preox, you MUST disconnect the vent circuit proximal to the viral filter before removing the mask. Otherwise, COVID will be sprayed all around the room!!!!! See Triple C below.

High-Flow Nasal Cannula

Aerosol risk seems no greater than standard NC and is mitigated by surgical mask (https://ccforum.biomedcentral.com/articles/10.1186/s13054-021-03512-w)

BVM with Viral Filter

* If you don’t have a vent available

* Turn BVM flow up to flush rate, higher flows do not translate to patient end of the bvm

* Place viral filter between BVM stem and mask

* Ideally, a NIPPV mask should still be placed to allow good seal with you away from the patient or just hold two hands on the mask in a thumbs-forward grip

from Safer Airways

* Addition of nasal cannula underneath will allow CPAP with PEEP valve if needed. I would only turn NC up to 4-6 lpm if this used. Often NC fits with no mask leak. More preferable is porting the oxygen through a luer or pressure connection port.

Optimal Preoxygenation

The first video uses a nasal cannula, the second avoids the NC leading to even less mask leak:

The Nasal Cannula Video (Next Video avoids using Nasal Cannula)

EMCrit CPAP Set-Up without the NC

Here is a Pict

<a href="https://emcrit.org/wp-content/uploads/2020/03/without-corrugated-scal...