Intubation

General Considerations

• Intubation is an aerosol generating medical procedure.
• Early controlled, protected intubation is recommended for patients with Influenza-like Illness (ILI) or Severe Acute Respiratory Infection (SARI) at high risk of deterioration.
• Only the minimum number of staff required for the procedure should enter the room (1 MD, 1 RT, 1 RN).

Isolation

• Intubations outside of the operating room will be performed in a negative pressure room, or an isolation room with a HEPA-filter with the door strictly closed.
  • If negative pressure rooms are in short supply, 1 negative pressure (or isolation room with a HEPA-filter) should be reserved for AGMP and the patient should subsequently be transferred to an isolation room.
• During AGMP (intubation, bronchoscopy, tracheostomy, extubation), a Level 4 (blue) gown is recommended on top of Personal Protective Equipment (PPE) for airborne precautions.

Safety Officer & Runner

• A Safety Officer (additional staff member not involved in the procedure, standing outside of the room) is required to guide staff through don and doff of PPE to ensure strict adherence to protocol.
• Staff should doff PPE one at a time to allow strict observation by the safety officer.
• A Runner (RN) should be outside the room to provide any additional drugs and equipment required, so staff involved in the procedure do not leave the room until the procedure is complete.

Procedure / Technique Considerations

• The most skilled operator available should perform intubation.
  
• Pre-oxygenate using a filter mask (Tavish) if available (otherwise use a non-rebreather mask).
• Ensure the use of high-efficiency hydrophobic filters in the ventilator circuit and the manual resuscitation bag.
  
• PEOPLE IN THE ROOM
  • Physician
  • Nurse
  • Registered Respiratory Therapist
• IN-ROOM MEDICATIONS
  • Propofol, Fentanyl – for anesthesia
  • Rocuronium – for paralysis
  • Phenylephrine, Epinephrine – for hemodynamic management
• OUTSIDE THE ROOM
  • Runner (RN, in droplet precautions)
  • Safety officer (in droplet precautions)
  • A second intubator dressed in PPE ready to enter.
    
• Use video laryngoscopy (e.g. Glidescope) rather than direct laryngoscopy, so the operator’s head remains farther away from the patient during intubation.
• Avoid awake fiberoptic intubations.
• Do not topicalize the airway – this will aerosolize the virus.
• Rapid sequence intubation with paralysis is recommended to minimize coughing/aerosolization during the procedure if no significant contraindications exist.
• The patient will become hypoxic.
• If possible, avoid bag-valve-mask ventilation.
  • If required (can’t intubate, severe hypoxia), use
    • two-person technique to improve the seal between mask and face.
    • use minimal possible tidal volume required to rescue oxygenation.
  • Consider inserting LMA or another supraglottic airway.

IntubateCOVID is an international registry.
One of their publications can be found here.