Airway Considerations & Management

#### Airway Considerations

- Do not intubate unless confident to perform procedure, consider use of teleconsultation or wait for personnel who can provide advanced airway management.
- Minimize aerosol & exposure of medical personnel to preserve deployed trauma care capacity.
- Always wear best available PPE for intubation and aerosolizing procedures, ensure hand hygiene.
- Assess intubation need based upon work of breathing. Early intubation may allow a controlled intubation, preventing complications.
- COVID19 patients usually present with intact airways and do not need cricothyroidotomy.
- Better to choose early intra-theater critical care facility transfer over early cricothyroidotomy.
- Cricothyroidotomy without ventilator use consumes scarce resources (manpower required to bag-ventilate the patient with PEEP, inefficient delivery of oxygen via bag-ventilation, & increases aerosolization risk.

#### COVID-19 Intubation

- Limit intubation procedure to one additional PPE-protected assistant at least 2 meters away.
- Passively pre-oxygenate with 100% O2 for at least 5 minutes. Place surgical mask on the patient, on top of nasal cannula or NRB mask, if tolerated.
- Use strict RSI technique – do not use bag-valve-mask ventilation if possible. If using BVM, place viral filter in-line if available.
- Use video laryngoscopic-guided intubation (Glidescope) if available to minimize health care personnel exposure. If unable to intubate or obtain vocal cord visualization on first pass, consider the placement of an iGel LMA with viral filter.
- Ventilate with the BVM and PEEP valve until oxygenation is adequate. Then, consider re-attempting and/or teleconsultation.
- Check EtCO2 and auscultation to confirm placement since chest X-Ray may not be available to confirm tube placement.
- Place as largest endotracheal tube possible as secretions may be an issue.
- Use heated humidification device (e.g. Hamilton H900) or heat and moisture exchanger (usually HME-F with microbiological filter) via INHALATION circuit of the ventilator tubing if available.
- Use HEPA filter (microbiological filter) or HME-F via EXAHALTION circuit of ventilator tubing if available.

COVID-19 Intubation Guide