COVID-19 Airway Mgmt

UH-CMC Emergent Airway Management Best Practice in Suspected COVID-19 Patients

DRAFT – 3/16/20

Department of Emergency Medicine, Division of Resuscitation & Critical Care

1.     Reduce Provider Exposure

a.     Enhanced Droplet PPE for all providers in the room

                                               i.     Hair cover

                                             ii.     Eye protection

                                            iii.     Gown

                                            iv.     Gloves

                                              v.     N95 Mask – Appropriately fitted

b.     Most experience available airway manager should be intubating (attending or senior resident)

2.     Appropriate Preparation

a.     Manage airway in negative pressure rooms

b.     Pre-oxygenate with non-rebreather mask (NRB) for 3-5 minutes

                                               i.     Consider placing simple mask over exhalation ports to avoid aerosolization

                                             ii.     Consider addition of apneic oxygenation via NC to support oxygenation through attempt

c.     Avoid bag-mask ventilation (BVM), if at all possible

                                               i.     Place HEPA filter between mask and bag if required

d.     Avoid heated high-flow O2 (i.e. Vapotherm) and positive pressure ventilation (i.e. CPAP/BiPAP) – both increase aerosolization and ultimately are unlikely to prevent intubation in this cohort

e.     Avoid nebulized medications

3.     Adhere to Rapid Sequence Intubation practices

a.     Rapid push of sedation and paralysis back-to-back

                                               i.     Avoid awake intubation due to high potential for aerosolization

b.     Avoid bag-mask ventilation (BVM) unless desaturation between attempts

                                               i.     Place HEPA filter between mask and bag if required

c.     Utilize high-dose neuromuscular blockage agents and wait for onset time

                                               i.     Rocuronium 1.2 mg/kg – 60 second onset

                                             ii.     Succhynocholine 1 mg/kg – 45 second onset

d.     Utilize video laryngoscopy (VL) to maximize first pass attempt and reduce distance from airway

e.     Utilize entirely disposable airway equipment

4.     Post-Intubation Care

a.     Place immediately on ventilator (limit bagging)

b.     Initiate low-tidal volume ventilation (~6 cc/kg)

c.     Adhere to PEEP table (consider high PEEP table)

d.     Minimize detachments from ventilator