Intubation Guideline

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Intubation Guidelines for patients with suspected or confirmed Covid-19

Your Personal Protection is the Priority!!

All Intubations should be performed in the ICU if possible!

Practice appropriate hand hygiene before and after all procedures.

All standard equipment should be pre-checked: IV access, instruments, medications, ventilator, suction etc.

An LMA is to be available and readily accessible at the bedside in case of a failed intubation. Emergency Cricothyrotomy tray is to be available in the anteroom for emergencies.

Intubate in airborne precautions wearing appropriate PPE

  • Fit tested N95 mask
  • Face shield
  • Hair cover
  • Gown
  • Gloves

Limit the number of healthcare providers (3 only) in the room where the patient is to be intubated : One RT, one RN and one physician.

The most experienced physician available should perform the intubation, if possible.

Standard monitoring, i.v. access, instruments, drugs, ventilator and suction should be pre-checked.

The glide scope should be utilized on the first attempt. Avoid awake, fiberoptic intubation unless specifically indicated. Atomized local anesthetic might aerosolize the virus.

Plan for rapid sequence induction (RSI) and ensure that a skilled assistant is able to perform cricoid pressure. RSI techniques may need to be modified if the patient has very high alveolar-arterial gradient and is unable to tolerate 30 s of apnea, or has a contraindication to succinylcholine. If manual ventilation is required, small tidal volumes should be applied.

Administer five minutes of preoxygenation with oxygen 100% and use a RSI technique in order to avoid manual ventilation of patient’s lungs and potential aerosolization of virus from airways.

Ensure high efficiency hydrophobic filter is interposed between facemask and breathing circuit or between facemask and a self-inflating ventilation bag (Bag-Valve Mask).

Intubate and confirm correct position of endotracheal tube with either CXR or consider using ultrasound to confirm bilateral lung sliding.

Institute mechanical ventilation and stabilize patient.

All airway equipment must be decontamination and disinfection according to appropriate hospital policies.

After removing protective equipment, avoid touching hair or face before washing hands.

References

Orser, D. B. (2020, March 10). Coronavirus and Safety Precautions. Retrieved March 11, 2020, from University of Toronto, Faculty of Medicine, Department of Anesthesiology and Pain Medicine: https://wwww.anesthesia.utoronto.ca/news/coronavirus-and-safety-precautions