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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.
- 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.
- Support each other by using “call/response” checklists and buddy checking PPE.
- 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.
- Patients need oxygenation, and to a much lesser extent ventilation, but not tubes per se. Whatever method achieves that in an emergency is okay.
- 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.
- 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.
- 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.
- Move the bed. True 360 degree access to the bed makes a difference.
- 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.
- By and large, different types of PPE should not affect intubation success if the team is highly-skilled.
- 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.
- 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.
- 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.
SASA (South African Society of Anaesthesiologists) COVID-19 protocol and recommendations