COVID-19 / Coronavirus Outbreak: Protecting The Airway - Endotracheal Intubation

Coronavirus / COVID-19 Procedures
JoVE Journal
Coronavirus / COVID-19 Procedures

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Wunderlich, R., Stricker, E., Goll, A., Nikomanis, P. S., Häberle, H., Münch, A. COVID-19 / Coronavirus Outbreak: Protecting The Airway - Endotracheal Intubation. J. Vis. Exp. (159), e6430, (2020).


In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and procedures have to be taught to medical staff to reduce the risk of infection. COVID patients often need mechanical ventilation due to progredient respiratory insufficiency, so an endotracheal intubation becomes a critical procedure in managing these patients. This procedure has an increased risk of infection due to aerosol formation and working with an unsecured airway. Patient safety should not be neglected, and complications like hypoxaemia and aspiration should be avoided. At the same time, personal protection from infection is of utmost importance becuase human resources in a pandemic crisis must be preserved. This video shows the procedure of endotracheal intubation while taking personal infection protection into account. 


The key objectives of this protocol are reduction of aerosol formation and rapid sequence induction.

There are several critical recommendations for this protocol: Hold a low threshold for early intubation, use video laryngoscopy in the first line, avoid high-flow oxygen-therapy to reduce aerosol formation, have as few personnel as possible in the room, and use checklists for preparation and procedure.

  1. Prepare the necessary materials outside the patient room.
  2. Give an overview to the team. 
  3. Donn personal protective gear (gown, cap, goggles, gloves) as well as additional gear for working with an open airway: FFP3 / N-95 mask, visor, and a second pair of gloves.
  4. Connect double filters to the ventilator and check connection points of the ventilator tubes.
  5. Inform the patient about the pending procedure and obtain consent.
  6. Obtain hemodynamics monitoring (ECG, SpO2, NBP).
  7. Optimize the patient's position and intubation requirements by elevating the upper body.
  8. Test the suction unit.
  9. Test venous access (minimal 2).
  10. STOP the whole team: Follow a 10 seconds for 10 minutes principle (discuss problems, opinions, facts, plan) and process checklist.
  11. Stop the oxygen supply (leave O2 nasal cannula in place), and remove the patient's protection mask.
  12. Place the respiratory mask and tighten it with both hands.
  13. Start the oxygen supply through the O2 nasal cannula at 3 liters/min.
  14. Begin pre-oxygenation with FiO2 1.0 with the ventilator (CPAP without pressure support, PEEP 5 mbar) for 3-5 minutes.
  15. Check hemodynamics and prepare vasopressors for hypotension.
  16. Quickly administer anesthetics and muscle relaxants, and wait at least 45 seconds. This is done to achieve good intubation conditions and to ensure that the patient does not cough during intubation.
  17. Stop the oxygen supply through the nasal cannula, then stop the ventilator.
  18. Remove the respiratory mask and place it safely beside the patient.
  19. Perform endotracheal intubation using video laryngoscopy to avoid getting too close to the unprotected airway. Block the cuff as soon as the tube is in place.
  20. Connect the ventilator with the integrated closed suction unit.
  21. Check connection sites of the ventilator tubes.
  22. Start the ventilator.
  23. Check for correct tube placement with capnography and auscultation.
  24. Remove the O2 nasal cannula
  25. Fix the endotracheal tube.
  26. Remove outer pair of gloves.
  27. Insert nasogastric tube.

In case of an unexpectedly difficult airway, supraglottic airway devices are preferred over mask ventilation due to lower risk of aerosol formation. All necessary material needed for a difficult airway should be placed outside the contaminated area and quick access to an additional assistant must be ensured.


No conflicts of interest declared.