Safe Intubation

Oxygen delivery for patients 

  • Oxygen delivery via nasal prongs is safe

  • High flow nasal cannulas (HFNC), and nebulization of medications, can increase aerosolization of viral particles, increasing transmission. Their use may be safe in an airborne precaution negative pressure room 

  • Delivery of medications via metre dose inhaler is safe 

  • There is evidence that use of CPAP or BiPAP may increase transmission of virus (as seen for SaRS) so their use is not recommended. Further, there is evidence from MeRS coronavirus that non-invasive ventilation does not improve outcome, and has high failure rate, essentially delaying intubation 

  • Avoid deep suction 

 

Before the intubation 

  • Intubation is deemed a high-risk procedure with aerosolization of viral particles, and transmission to care providers during SaRS-CoV

  • Intubation should be done early in a controlled manner to reduce transmission risk. Any patient with high O2 requirements (FiO2 increasing), respiratory distress, or hemodynamic instability should be identified early for intubation

  • Airborne isolation negative pressure room, with all people present in appropriate PPE (at least N-95 and gowns) 

  • Most skilled person to reduce attempts using Rapid Sequence Intubation (RSI) – (Ketamine / Rocuronium/ Phenylephrine)

  • All necessary equipment should be available in the room to reduce in/ out traffic

 

Pre-oxygenate  

  • With adequate pre-oxygenation, BVM can ideally be avoided 

  • BVM and coughing during laryngoscopy can general aerosols use an Exhalation filter between the mask/ endotracheal tube and bag

  • Adequate sedation required to prevent agitation, risk of dislodging PPE

Intubation 

  • Video laryngoscopy recommended 

  • Flexible bronchoscopy as backup if difficult intubation suspected 

  • ETCO2 for tube placement confirmation (no auscultation given PPE) 

References

https://www.ncbi.nlm.nih.gov/pubmed/30884185 (MeRS)

https://www.ncbi.nlm.nih.gov/pubmed/32052373

https://www.publichealthontario.ca/-/media/documents/lanyard-removing-putting-on-ppe.pdf?la=en

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