- 1) Minimize viral aerosol formation and direct exposure of medical personnel.
- 2) Use the best available PPE for high risk procedures like endotracheal intubation. (See Appendix B.)
- 3) Gauge the need for inserting an advanced airway on the patient work of breathing. COVID-19 patients decompensate rapidly – a low threshold for intubation allows more time for preparation and may prevent complications.
- 4) If the COVID attending provider does not feel comfortable with placing an advanced airway, consider teleconsultation and/or waiting for arrival of more experienced personnel (e.g., evacuation team). Never try to place an advanced airway unless you know how to do it.
- 5) One assistant is sufficient during intubation in most cases; however, an additional assistant can be standing by in the “warm” zone at least 2 meters away wearing appropriate PPE.
- 6) Passively pre-oxygenate with 100% O2 for at least 5 minutes. Consider placing a surgical mask on the patient (over top of nasal cannula or non-rebreather mask).
- 7) Utilize strict rapid sequence intubation technique – avoid BVM ventilation if possible. If available, place viral filter in-line during use of BVM.
- 8) Utilize video laryngoscopy (i.e. GlideScope) if available for intubation to limit direct exposure. If unable to intubate or obtain adequate vocal cord visualization on the first pass, consider the placement of a laryngeal mask airway (LMA) with viral filter. Ventilate with the BVM and PEEP valve until oxygenation is adequate. Then, re-attempt the procedure.
- 9) Chest X-Ray may not be available or feasible to confirm tube placement. Utilize end-tidal carbon dioxide (EtCO2) monitoring and auscultation to confirm placement.
- 10) General guide for tube size and depth is as follows: for males use 8.0 endotracheal tube (ETT) inserted to 25cm at the incisors; for females use 7.0 ETT inserted to 23cm at the incisors. In general, place as large an ETT as possible since secretions may be an issue.
- 11) If available, place heated humidification device (e.g., Hamilton H900) or heat and moisture exchanger (HME) in the INHALATION circuit of the ventilator tubing. If available, place a HEPA filter (microbiological filter) or HME-F (HME plus microbiological filter) in the EXAHALTION circuit of ventilator tubing.