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

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.

Dearest colleagues. The aims of early intubation in COVID-19 patients with respiratory failure are both to prevent aerosolization of respiratory tract fluids and avoid intubation under emergency conditions.

A low threshold for early intubation of COVID-19 patients should be held and a modified rapid sequence induction with videolaryngoscopic intubation utilized. High-flow or non-invasive ventilation therapy should be avoided, and if not possible, used for the shortest period of time.

Fiber optic intubation should also be avoided due to risk of aerosolization. All necessary equipment for intubation is prepared outside of the patient's room.

The team should be kept to the minimal number of personnel required to carry out the procedure. Typically, this would consist of one intubating doctor, a doctor with oversight who also manages the cardiovascular system, a nurse or operating department assistant to operate the ventilator, and a second nurse or operating department practitioner to apply the anesthetic agents and supply intubation equipment.

Additionally, there should be a runner assigned to wait outside of the room. In case additional equipment or materials are needed, an intubation checklist, which is tailor-made by every hospital according to their resources will now be carried out by the second doctor and will be clearly communicated to the team.

The airway trolley is placed outside of the room so that all potential and necessary airway equipment is quickly available. This includes supraglottic airway devices, such as laryngeal mask airways and esophageal tracheal double-lumen airways. The on-call EMT tracheostomy team should also be contactable and the telephone number known.

The connecting ports of the prepared ventilator are tested. An HME filter is connected between the Y-piece and the respiratory mask. The patient is informed of the anesthesia and intubation procedure in order to attain informed consent.

Complete vital sign monitoring is to be carried out and the ECG tone switched on. The working environment must be optimized. Ensure enough space is around the bed. The pillow is removed, and the patient positioned in a head-up position. The suction system must be fully functional with the suction catheter attached and in reaching distance of the intubating doctor. The patient should have a minimal of two intravenous cannulas, which are tested prior to intubation.

Before beginning the procedure, the team must follow a 10 second for 10 minute principle where facts, procedural planning, potential complications, and team roles are clarified and outstanding questions can be answered. The second doctor also reads and ensures that the recommendations in the airway protection checklist in COVID-19 patients is sufficiently completed. The procedure may begin once everything is clarified.

The oxygen supply to the nasal cannula is turned off. The patient's protective mask then removed. The respiratory mask is placed and held directly on the patient's mouth and nose with a C-grip technique. As soon as the mask is airtight, oxygen is provided through the nasal cannula at a flow rate of 3 liters per minute. The ventilator is set to a CPAP mode without pressure support and with a PEEP of 5 and FI02 of 1. The patient should be pre-oxygenated for a total of three to five minutes.

Meanwhile, the patient's cardiovascular state is monitored, and if required, catecholamine therapy initiated. Now, the five minutes are over. In the context of a rapid sequence induction, all anesthetic agents are rapidly applied. The purpose is to achieve a rapid and deep state of anesthesia without eliciting a cough reflex or hiccup. There will be a 45-second pause after the application of muscle relaxants.

The oxygen supply over the nasal cannula is stopped. However, the nasal cannula is left in place. The ventilator is also paused. The respiratory mask is either hung to the side or placed in a kidney dish next to the patient's head and held by the assistant positioned near the ventilator. Intubation will now be attempted through videolaryngoscopy and with an endotracheal tube with a pre-positioned bougie within. It is important to maintain as much distance as possible between the intubating doctor and the patient.

After the removal of the bougie, the endotracheal tube cuff must be blocked quickly to prevent aerosolization. The assistant detaches the respiratory mask from the breathing circuit, and places this, in turn, in a kidney dish. A closed suction system is attached to the breathing circuit and once any leaks are eliminated, ventilation can be continued.

The tube position is confirmed through capnography and auscultation. Contamination can be minimized by having a dedicated stethoscope for each patient, which is left by the patient's bed. Now, the nasal cannula are cut and removed. The endotracheal tube is then fixed. The first pair of gloves are removed and disposed of.

Now, a nasogastric tube should be inserted and its position checked and then fixed. Per the procedures, difficult airway algorithms are well established and are also relevant in COVID-19 patients. The airway or emergency trolley is pre-prepared with all potentially necessary equipment and is placed outside of the patient room.

An allocated runner is made available to pass any equipment on to the intubated team. Supraglottic airways, such as a laryngeal tube should be utilized early on in the algorithm. This is because the potential for leakage or aerosolization of respiratory tract droplets is lower than when compared to bag mask ventilation through a normal respiratory mask. If a second intubation attempt is required, then cricothyroid pressure can be applied. If a further attempt is required, then the second doctor from the team may carry this out.

Early consideration of the need for additional personnel or technical assistance is important as donning of personal protection equipment requires significant time. If a surgical airway is necessary, such as an emergency tracheotomy, then EMT colleagues must be informed early on. Extubation should be carried out by a team of two individuals with full personal protection equipment.

The first person stands next to the ventilator. The second loosens the endotracheal tube fixation tape and operates the closed suction system. The patient is ventilated with an FI02 of 1.0 prior to extubation and with a PEEP of 5. The ventilator is placed on standby immediately prior to extubation. The patient must then be continuously suctioned whilst the endotracheal tube is carefully removed.

The breathing system may not at any point be disconnected. A tight-fitting respiratory mask is placed on the patient covering the mouth and nose, and all vital signs with particular attention to the respiratory function must be monitored.

Thank you.