key: cord-0798791-c3x2mjoa authors: Brown, Calvin A.; Mosier, Jarrod M.; Carlson, Jestin N.; Gibbs, Michael A. title: Pragmatic recommendations for intubating critically ill patients with suspected COVID‐19 date: 2020-04-13 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12063 sha: 594667f66550754efe6586a03cf19470f95859aa doc_id: 798791 cord_uid: c3x2mjoa nan As the novel coronavirus (COVID-19) spreads across the world, teams must develop airway management strategies that protect both patients and staff. While the fatality rate for COVID-19 is not clear, early data suggest that it is likely between 2% and 4%. 1, 2 The case fatality rates with Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) were 9.6% and 34.4%, respectively. 3 While not as lethal proportionally, COVID-19 has resulted in more deaths worldwide, a fact which speaks to its communicability and the need for protective strategies when caring for infected patients. Transmission to healthcare workers is inevitable and more than 3000 cases have been reported so far. 3 Thoughtful preparation will protect healthcare teams as they strive to care for those who are highly infectious. Basic airway management principles apply to known or suspected COVID-19 patients, as they do with others who are critically ill. There are unique considerations with airway management under airborne precautions, however, and modifications to the standard approach are essential to minimize viral spread to care providers, particularly during aerosolizing procedures like endotracheal intubation. While our collective experience is rapidly evolving, the evidence basis for many In patients who have developing respiratory failure requiring oxygenation and ventilatory support, early tracheal intubation is recom- Aerosolization of viral-containing droplets may happen during intubation and spread can occur to personnel or nearby patients. Whenever possible, intubation should take place in a negative pressure room. Optimally, a dedicated negative-pressure "airway procedure room" should be identified in the emergency department (ED) and other care locations in which most, if not all, intubations would take place. The door to the patient room should remain closed as much as possible and bedside care clustered in order to minimize entries and exits. Negative pressure rooms may not be available at all times in the ED. Although mitigating viral spread is always crucial, intubating in a standard airflow room requires heightened attention to reducing aerosolization (Table 1 ). Patients with COVID-19 will be intubated for current or expected hypoxemic respiratory failure and thus there is a delicate balance between the risk of rapid desaturation with induction and the risk of in low-risk patients. Manual bag-assist or positive pressure ventilation (PPV), although not absolutely contraindicated, should be used only if clinically required. If bag-assist is needed, it should be performed as a 2-person procedure with a 2-handed (thenar grip) mask hold. This will improve mask seal and limit leak around the margins of the mask. 8 In the ED, rapid sequence intubation (RSI) is the most common approach for airway management. 9 In patients with COVID-19, RSI remains the preferred approach as the induction agent and neuromuscular blocking agent (NMBA) act synergistically for rapid-onset apnea and elimination of the cough reflex. During RSI, higher-dose NMBAs should be used (1.5 mg/kg IV of rocuronium or 2.0 mg/kg IV of succinylcholine) in order to prevent incomplete or slow-onset paralysis. After drug administration, it is imperative to allow the NMBA to take full effect (45-60 seconds) before starting laryngoscopy to eliminate the possibility of a patient reaction, coughing or regurgitation. Awake intubation techniques should be used only when absolutely necessary because of the risk coughing during the procedure. High-efficiency particulate air (HEPA) filters should be placed in-line when PPV is being performed. Depending on the mode of ventilation, they should be placed between: 1. The bag-valve and inflatable mask or endotracheal tube (ETT). 2. The NIPPV machine and the mask (as close to the mask as possible). 3. The ETT and the Y-connector of a ventilator. After tracheal tube placement, the ETT balloon should be inflated immediately and cuff pressure should be checked before the bag-valve is attached or tube confirmation occurs. During ongoing patient care, providers should communicate closely with respiratory therapists to limit ventilator checks and disconnects. To avoid confusion, each provider should verbalize their actions and have those actions confirmed and acknowledged by the rest of the team. If a disconnect is required (ie, a transition from a room to a portable ventilator) this should be done at end-expiration. Consider temporarily placing a smooth clamp on the ETT at end-expiration before disconnecting to further avoid expelling viral particles, and to avoid loss of positive end-expiratory pressure leading to de-recruitment of alveoli. First-attempt success reduces peri-intubation adverse events. 10 Steps implemented to augment first-attempt success are paramount. For patients with COVID-19, the main goals are to minimize the need for interposed bag-mask ventilation and to reduce the risk of hypoxic complications. We recommend that each airway team develop and use a checklist to ensure compliance with protective steps. Additionally, team leaders should clearly delineate roles and the airway management plan using closed-loop communication with verbal confirmation by team members. Providers should optimize preoxygenation, maximizing time for a successful first-attempt. Intubating hypoxemic patients who will further desaturate rapidly after RSI meds are administered places them at risk of critical hypoxemia or death during the procedure. 11 The optimal preoxygenation strategy is not clear, and the risk of desaturation needs to be weighed against the availability of equipment, resources, and the potential for viral spread. If a negative pressure isolation room is not available, high oxygen flow rates should be avoided. Once RSI medications are administered, rapid desaturation may begin as soon as the patient is apneic. The speed which this happens, depends on the effectiveness of preoxygenation and the severity of airspace disease. Traditional teaching has been that an intubation attempt should be aborted when the saturation falls below 93%. Since this may happen quickly in patients with COVID-induced acute respiratory distress syndrome, clinicians should prepare for and tolerate, during laryngoscopy, brief periods of oxygen saturations less than 90% if that brief period allows successful tube placement and obviates the need for rescue bag-mask ventilation. The most experienced available clinician should intubate. We strongly recommend the routine use of video laryngoscopy as it improves firstattempt success. 9 A video (indirect) view should be used for tracheal tube placement. We recommend a bougie-first intubation technique to further increase first-attempt intubation success when standard geometry video laryngoscopy is used. 12 If the initial intubation attempt is unsuccessful, consider immediate placement of a SGA, fit with a HEPA filter, connected directly to a ventilator. A SGA that could facilitate intubation through the device would be preferred. This approach will allow for oxygenation and ventilation while avoiding manual bagging and aerosolizing viral particles in between attempts. If rescue mask ventilation is performed, it should be a 2-person procedure. The most experienced operator should hold the mask using a thenar grip technique with an oral airway in place. We recommend a low volume bagging approach. The We recommend a 3-person intubation team to include a nurse, respiratory therapist, and intubating clinician. During the SARS outbreak, cross contamination was highest when >3 providers were in the room. 14 Ideally, a second airway manager should be donned outside the room and ready to assist immediately if needed. After the procedure, adhere to coached doffing steps including hand hygiene. Providers should not touch their face until this has occurred. We encourage formal team debriefing following all intubations. Video laryngoscopy allows better intubator-to-patient distancing and the ability for indirect visualization of tracheal tube placement. Using the video screen for visualization obviates the need to get close to or look through the patient's mouth to intubate. All disposable airway equipment should be placed in a sealed biohazard bag after the intubation. Supporting equipment that is considered contaminated because of patient proximity (VL screen and stand, etc) should be disinfected with alcohol-based cleaning wipes. Optimally, all protective measures would be used with each intubation; however, for clinicians in resource-strapped locations, out-ofhospital providers who may be working in austere environments, or at times when a patient is in extremis and the need for intubation is immediate, this may not be possible. In these circumstances, the following should be considered a list of minimal "must dos" to intubate patients with COVID-19. ED airway management will be inevitable in many patients with COVID-19 and safety of both patients and providers is essential. Information is evolving quickly and these recommendations are meant to serve as a framework to safely intubate the critically ill patient with COVID-19. Calvin A. Brown III MD https://orcid.org/0000-0002-1313-5241 Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China Novel corona virus (2019-nCoV). WHO Bull 2020-data as reported Characteristics of and important lessons from the Coronavirus Disease 2019 (COVID-19) outbreak in China. Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention COVID-19 Airway Management Expert recommendations for tracheal intubation in critically ill patients with Novel Coronavirus Disease 2019 Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients Anesthesia and SARS Efficacy of facemask ventilation techniques in novice providers Video vs. augmented direct laryngoscopy in adult emergency department tracheal intubations: a National Emergency Airway Registry (NEAR) Study The importance of forst pass siccess when performing orotracheal intubation in the emergency department The physiologically difficult airway Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial Clinical communication from The Anesthesia Patient Safety Foundation (APSF) Pragmatic recommendations for intubating critically ill patients with suspected COVID-19