Episode 37: Airway management for COVID-19

Back again with Dr. Ross Hofmeyr (@rosshofmeyr), anesthesiologist in the Department of Anaesthesia and Perioperative Medicine at the University of Cape Town, to discuss an expert’s perspective on airway management in the COVID-19 patient.

Takeaway lessons

  1. Good practices for intubating COVID patients are, by and large, good practices for intubating anybody. Using a standardized protocol, appropriate PPE, applying best practices to optimize success, and pre-assigning roles has no downside.
  2. Support each other by using “call/response” checklists and buddy checking PPE.
  3. Ross’s protocol: one attempt at intubation, immediate placement of supraglottic airway if it fails, then proceed to another attempt. First line with video laryngoscopy using a Macintosh blade. No mask ventilation (to limit aerosolization) except as third line if SGA fails. Mask with two hands, two operators, and a PEEP valve.
  4. Patients need oxygenation, and to a much lesser extent ventilation, but not tubes per se. Whatever method achieves that in an emergency is okay.
  5. You need PEEP to preoxygenate the hypoxic COVID patient. High flow nasal cannula is okay, but a BVM with PEEP valve provides real PEEP and usually improves preoxygenation. HFNC with a mask on top is less clear as the large cannula can cause air leak.
  6. Learning to bag-mask ventilate on mannequins teaches bad habits. Learning in the OR with real humans and an anesthesia bag is a better place.
  7. Intubate everyone with head of bed elevated PLUS head in a sniffing position. Blankets are better than pillows. Start with more elevation than you need; it’s easier to remove than to insert.
  8. Move the bed. True 360 degree access to the bed makes a difference.
  9. Proper preparation makes most of the difference to success. Even experienced anesthesiologists have dramatically reduced first-pass success when removed from their usual OR setting, likely due to less preparation.
  10. By and large, different types of PPE should not affect intubation success if the team is highly-skilled.
  11. Ross’s team favors induction with fentanyl, etomidate, and succinylcholine (unless hyperkalemic, then rocuronium). The small advantage in speed with sux is worth it in these rapidly-deoxygenating patients.
  12. Use a verbal call/response checklist to make sure nothing has been missed, slow down the pace, and create a shared mental model among the team (particularly if not everyone is part of the usual group). This only takes a significant amount of time if you actually find deficiencies that need correcting (in which case you’ll be glad you took it), and it adds value almost every time.
  13. Many patients will be dehydrated and hypovolemic at the time of intubation, particularly if they’ve been on non-invasive for some time (often not eating/drinking) and most of all if they’ve been on non-humidified oxygen, such as regular cannula and/or masks.

References

SASA (South African Society of Anaesthesiologists) COVID-19 protocol and recommendations

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