Start with a free account for 3 free CME credits. Already a subscriber? Sign in.
Free Episode

“What if I Get Called In”...COVID Airway Management for the Non-Intensivist

Scott Weingart, MD and Mizuho Morrison, DO
00:00
67:08

No me gusta!

The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below.

COVID airway management creates a lot of anxiety for those of us non-intensivists. Dr. Mizuho Morrison interviews Dr. Scott Weingart (founder of EMCrit.org and Chief of the Division of Emergency Critical Care at Stony Brook University Hospital, NY) on the basics of COVID airway management.

Released 4/20/2020

COVID: The big picture and escalation of care

Bottom line:

  • Respiratory support for COVID “happy hypoxemics”: nasal cannula → non-rebreather → high-flow nasal cannula → CPAP

  • COVID “happy hypoxemics” may require intubation if they have: 

    • Any increased work of breathing (tachypnea is common but they should be a “happy tachypneic”)

    • Any sort of altered mental status

    • Rising CO2 on serial VBGs

    • Oxygen saturation consistently below 80-85%

 

COVID airway management is different from others because:

  • These patients rapidly desaturate

  • We are concerned about aerosolized virus during intubation and how that affects our safety, our staff’s safety, and the surrounding environment

 

The “happy hypoxemic”:

  • These COVID patients are hypoxemic (low oxygen level in the arterial blood) but not hypoxic (low oxygen level in the tissues)

  • Monitor these patients closely as they can quickly decompensate 

Step-by step approach to respiratory support for the “happy hypoxemic”:

  • You’ll know if your patient is failing these respiratory support measures and may require intubation if they have: 

    • Any increased work of breathing (tachypnea is common but they should be a “happy tachypneic”)

    • Any sort of altered mental status

    • Rising CO2 on serial VBGs

    • Oxygen saturation consistently below 80-85%

  • Obtunded or crashing on arrival? Just intubate!

 

Step 1. Start with nasal cannula 

  • Put on nasal cannula at 6 to 10 L/min of oxygen with a surgical mask over the nasal cannula

 

Step 2. Move to non-rebreather

  • Put on a non-rebreather at 15 L/min (over top of nasal cannula) and reapply surgical mask

    • Why both? Non-rebreather at flow rates around 15L/min supplies 65-70% FiO2; non-rebreather + nasal cannula gets your FiO2 up to around 90%

  • Be sure to have these patients change position (the “rotisserie” method) every 1-2 hours

    • Start with upright in bed (head of bed at 80-90 degrees)

    • Lie on left side for 1-2 hours

    • Lie on right side for 1-2 hours

    • If able to tolerate, lie prone for 1-2 hours

 

Step 3. Move to high-flow nasal cannula

  • What is high-flow nasal cannula (HFNC)? 

    • Nasal cannula hooked up to a humidifier and heater

  • Scott starts with up to 100% FiO2 at 20 L/min → titrate up the flow by 10 L/min every 10 minutes, as needed

    • Can go up to 60 to 80 L/min; max flow rate depends on the device

  • Can generate a little bit of PEEP (4 to 7 cmH2O) at high flow rates (around the 30-40 L/min)

 

Step 4. Move to CPAP

  • CPAP provides more PEEP then high-flow nasal cannula, up to 15 cmH2O

  • While we generally do not use BiPAP in COVID, it is still a good choice for those with secondary disease (COPD, asthma)

  • If you do not have a CPAP machine available, see Scott’s CPAP mask + bag-valve-mask (BVM) +/- nasal cannula set-up at https://emcrit.org/emcrit/covid-airway-management/

 

COVID Intubation 

Bottom line:

  • The key is to ensure first-pass success and reduce exposure 

 

Before entering the room:

  • Highest-level physician should do the intubation; each additional attempt at intubation is a risk for exposure

  • Don PPE

    • Full hood/PAPR is ideal; at a minimum should include N95 covered by a surgical mask, full face visor, hair and neck covering, gown, and double gloves


Upon entering the room:

  • Preoxygenate using CPAP with a viral filter

  • Tools and set-up for first-pass success, including:

    • Video laryngoscopy preferred over direct laryngoscopy, if available (Hippo Education intubation procedure video)

    • Bougie + standard geometry blade OR hyperangulated blade + hyperangulated stylet, whichever you’re comfortable with

    • Endotracheal (ET) tube

    • Back-up plan → Laryngeal mask airway (LMA); scalpel (for cricothyroidotomy)

    • Whatever additional things the respiratory therapist wants to add to the end of the ET tube in order to avoid circuit disconnects (eg, in-line suction, heat moisture exchanger, viral filter)

    • Rapid sequence intubation (RSI) medications:

      • Scott prefers ketamine → can allow for dissociation if the patient is not tolerating preoxygenation 

      • Full dose of paralytic (rocuronium or succinylcholine, user preference)

    • Plastic sheet drape or clear box, only if it makes you comfortable

 

Intubation tips/tricks:

  • Induce and paralyze while the patient is sitting up

  • Reduce the number of people in the room during intubation (2 to 3 people max)

  • Wipe off the bougie with your gloved hand when removing it from the ET tube to remove COVID secretions

  • Scott does not recommend auscultation checks for ET tube placement

    • Visualize the ET tube passing through the cords

    • If blind intubation, 21 cm for women and 23 cm for men

    • Confirm with CXR and end-tidal CO2 with waveform

  • Do not use BVM until the patient is intubated; must have viral filter proximal to BVM

 

Additional resources: https://emcrit.org/emcrit/covid-airway-management/

 

COVID Ventilator settings and troubleshooting

Bottom line:

  • Initial COVID ventilator settings → volume AC mode, tidal volume of 8 mL/kg of ideal body weight, respiratory rate of 16 to 18 breaths per minute, FiO2 of 100%, and PEEP of 8 cmH2O

  • Ventilator alarming? Think “DOPE” (displaced tube, obstruction, pneumothorax, equipment failure)


Ventilator Settings: The basics

  • Initial COVID ventilator settings (Hippo Education Initial Vent Settings video)

    • Mode: volume assist control (AC)

    • Tidal Volume: 8 mL/kg of estimated ideal body weight 

    • Respiratory Rate: 16 to 18 breaths per minute

    • Fi02: 100%

    • PEEP: 8 cmH2O, unless they were on a higher PEEP prior to intubation

  • Check a blood gas after 15 to 20 minutes

  • Keep the patient moving → upright, left and right lateral recumbent position

  • Saturation goals should the same as before intubation (SpO2 around 85%)

    • Goals of 90 to 95% may result in lung-injuring ventilator settings

  • Keep tidal volume at 8 mL/kg of estimated ideal body weight

  • Leave on high FiO2 unless hyperoxic (oxygen saturation >95%)

  • Increase PEEP by 2 to 4 cmH2O every 15 to 20  minutes if SpO2 is <85%

 

Ventilator Alarms: Ventilator troubleshooting

  • “DOPE” - Displaced tube , Obstruction, Pneumothorax, Equipment failure

    • D: Rule out by checking end-tidal CO2 waveform

    • O: Pass in-line suction all the way down; if you cannot pass, you may have an obstruction

    • P: Check for pneumothorax with ultrasound

    • E: Do a circuit run to ensure there is no disconnect

  • If ventilator is still alarming → disconnect proximal to the viral filter, bag patient with a PEEP valve until RT comes, and check end-tidal CO2

 

Society of Critical Care Medicine’s COVID Guidelines: Scott’s 2-cents

Bottom line: 

 

IV fluids: 

  • Keep them dry, but not too dry

    • Cover insensible losses

    • Monitor urine output, make sure inferior vena cava (IVC) is not flat

  • Do not give national sepsis guidelines 20-30 mL/kg fluid bolus

  • Scott prefers Lactated Ringer’s 


Furosemide:

  • Only if iatrogenically fluid-overloaded


Vasopressors:

  • Norepinephrine sooner rather than later in a hypotensive COVID patient


Corticosteroids:

  • What Scott is doing:

    • 10 mg dexamethasone daily to any admitted patient with respiratory failure 

    • 60 mg methylprednisolone every 6 hours for those with rising inflammatory markers (CRP, D-dimer)

    • 125 mg methylprednisolone every 6 hours if critically ill


Anticoagulation:

  • COVID seems to be a disease of thrombosis

  • Scott’s team is giving prophylactic enoxaparin to all hospitalized patients

    • If D-dimer is rising, full treatment dose of unfractionated heparin or enoxaparin

 

Additional resources:

Ian L., Dr -

Is a surgical mask over a high flow nasal cannula less comfortable and less effective for the patient ? Dr Morgan Soffler reported the mask reduced the velocity of exhaled gas and does capture aerosols but warns this causes a moderate reduction in flush capacity with a need for a higher flow rate if work of breathing is increased -in Respiratory Medicine april 12 2020 -(From Practice Update) There are not enough negative pressure rooms -It is is here that for health staff a head visor surgical mask gown industrial raincoat head cover even a welders helmet is needed to otherwise protect health workers . -Also that could reduce risk is an open window a courtyard a balcony or climatised aerated tent .

To join the conversation, you need to subscribe.

Sign up today for full access to all episodes and to join the conversation.

To download files, you need to subscribe.

Sign up today for full access to all episodes.