RMH ICU COVID 19 Airway Management Version 1.1 (26 March 2020) Contributors David Camilieri Jai Darvall Jo Forrest Christian Karcher Megan Kelly Roni Krieser Eloise Marsiglio Bjorn Makein Emma Tonini

Safe Intubation

Principles • High risk procedure as intubation and ventilation are considered potentially aerosol

generating • PPE (droplet and airborne) • Only three staff in room (two doctors, one nurse) • Intubation to be performed by most skilled/experienced doctor as first operator • Front-of-neck access (FONA): Scalpel-bougie-ETT technique • Videolaryngospcopy as standard • Avoid/minimize Bag mask ventilation • BMV for preoxygenation and ventilation always in two-handed technique

Equipment There are pre-packed intubation kits kept in a dedicated rack

Dedicated Covid-19 Intubation trolleys will be set up either directly prior to intubation or in advance. The Intubation kits contain: ☐ Glidescope Mac4 blade (single use) ☐ ETT (6,7,8) ☐ 10ml Syringe ☐ ETT Tie ☐ ETT clamp

☐ Guedel #4 ☐ LMA 3,4,5 (double bagged) ☐ Scalpel #23 ☐ Bougie ☐ Closed Suction ☐ Sputum trap ☐ 1000ml N/Saline bag ☐ Hand pump set Size 3 and hyperangulated laryngoscope blades are available but not included in the Kit. These have to be added either in the preparation stage or from the Ante Room if required. Note: Hyperangulated blades should only be used by airway operators who are proficient in their use. We are ‘upgrading’ the existing BMV provided at each bedspace to COVID19 BMV assemblies (Figure 1) This upgrade consist of a viral filter HME and a capnometer connector.

Figure 1 COVID19 BMV Assembly

Intubation Process If possible, patients are to be intubated in negative pressure rooms. If Intubations have to occur in single rooms or open bays, the surrounding environment must be protected as good as possible (doors/curtains closed)

Staff Allocation The team consists of 6 staff members: The roll allocation is as follows:

Title Role Tasks Airway Lead Intubator

Most skilled/experienced doctor in airway management

• Assess airway • position patient • prepare BMV • connect etCO2 • prepare suction • Intubate patient • perform FONA

Team Leader Medical Lead • Medical Teamleader • Check venous access • Prime and attach fluid bag • Administer drugs • Monitor vital parameters • Airway Backup

Assistant Experienced ICU nurse • Establish/check monitoring • Calibrate etCO2 • Open ETT and attach syringe • Pass airway equipment to the Airway

Operator • help with bougie use and in bag-

valve-mask (BVM) ventilation. • Set and connect ventilator

Ante Room Runner Bedside nurse • Hand equipment from Ante room

to inside • Assist in case of cardiac arrest or

other complications Outside Supervisor Pod Nursing Teamleader • Intercom communication

• Call for help/equipment • Outside coordination

Outside Runner ICU nurse • Hand equipment from outside to Ante Room,

• Resus Trolley

Figure 2 Staff location

• Prior to entering the room, the team checks the equipment • If possible make an assessment of the patient’s airway to determine airway risk and

laryngoscope blade needed • Enter the room and take trolley plus Video Laryngoscope • Receive Handover from bedside nurse • Bedside nurse to leave and remain in ante room as Runner

Preparation in the patient room • Start executing tasks as above (i.e. prepare patient and equipment for intubation) • Once preparation finished, complete Intubation checklist

Intubation • The intubation is performed as a rapid sequence induction • No cricoid pressure unless clinically indicated • Do not ventilate prior cuff inflation • Confirm endotracheal tube position with etCO2 • Auscultate both lungs • Secure ETT with tie

Connection to the Ventilator • The Airway assistant takes off outer gloves and starts up the ventilator • Once ready, the patient is connected to the ventilator following the steps outlined in

Breaking Bag Mask Ventilator Circuit (below)

Difficult Airway Management • If primary endotracheal intubation is unsuccessful, a swap of operators may be

required • BMV is to be avoided if possible • Early insertion of an LMA may be required • If the patient can be oxygenated via LMA, the next step could be

o Intubation by second operator o Intubation through LMA

• Cricothyrotomy is to be performed as scalpel/bougie/ETT technique (using 6.0 ETT) see www.tinyurl.com/covid-fona

Airway Management Checklist

Figure 3 Airway Management Checklist

Link to pdf file: https://tinyurl.com/covid19-ett

Covid19 Intubation Checklist (backside)

Figure 4 Intubation Checklist

Link to pdf: https://tinyurl.com/covid19-ett-checklist

Safe Ventilatory Circuit Breaks Utmost caution needs to be exercised when disconnecting patients from ventilators. It is important to follow a strict protocolised system to exchange circuits for these patients.

Breaking Bag Mask Ventilator Circuit If a patient is on a BMV circuit (e.g. post intubation, see Figure 5) is to be connected to the ICU vent procedure should follow the protocol as:

1. Ensure adequate paralysis 2. Remove BMV DISTAL to HME filter (HME filter remains on ETT) 3. Put BMV aside a 4. Remove and discard HME filter 5. Attach inline suction to ETT 6. Attach Capnometer to Inline Suction 7. Attach ventilator to Capnometer 8. Unclamp ETT 9. Start ventilation.

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Figure 5 BMV ventilation

Figure 6 ICU patient ventilated

Breaking Transport Ventilator circuits ‘Single limb’ ventilator circuits such as those used in transport ventilators will have a viral filter attached to the ETT (Figure 7)

Figure 7: Transport ventilation Assembly

If a patient arrives in ICU on a transport ventilator, the procedure should proceed as follows:

10. Preoxygenate 100% 11. Ensure adequate paralysis 12. Move patient onto ICU bed connected to transport ventilator 13. Set ICU ventilator settings 14. Put transport ventilator in standby or switch off 15. Clamp ETT with ICC clamp 16. Break circuit DISTAL to HME filter (HME filter remains on ETT) 17. Remove HME filter and discard 18. Prepare ICU ventilator with inline suction and EtCO2 adapter (see Figure 6) 19. Connect patient to ventilator 20. Unclamp ETT 21. Start ventilation.

Breaking ICU Ventilator Circuits ‘Dual limb’ circuits on most ICU ventilators do not require an HME/viral filter. Those ventilators have built-in expiratory filters (see Figure 6) If the ICU circuit has to be broken, the procedure should proceed as follows:

1. Preoxygenate 100% 2. Ensure adequate paralysis 3. Pause ventilator 4. Clamp ETT with ICC clamp 5. Break circuit at the ETT 6. Replace circuit (or parts if required) 7. Connect patient to ventilator 8. Unclamp ETT 9. Start ventilation.

Transporting COVID19 patients COVID-19 patient transport between ICU and anaesthetising locations:

1. All confirmed or suspect COVID-19 patients who are intubated and mechanically ventilated in ICU requiring transport to an anaesthetising location will be transported on their existing ICU ventilator (not on an Oxylog or Hamilton transport ventilator).

2. This will require the ICU nurse to be present for transport, and to be responsible for operation of the Puritan Bennett 840 or 980 ventilator, which are less familiar to anaesthetic staff.

3. Transferring to the anaesthetic machine ventilator circuit can occur after placing the ICU ventilator on standby and clamping of the endotracheal tube PRIOR to circuit disconnection. The ICU ventilator circuit is then capped.

4. Return of the patient to the ICU ventilator at the conclusion of the case requires the ICU nurse to return and be present for transfer back to ICU.

5. Disconnection of the anaesthetic ventilator tubing should first occur PROXIMAL to the HME filter (ie. filter still attached to the clamped endotracheal tube) after stopping fresh gas flow through the anaesthetic circuit.

6. The HME filter is then removed and discarded as contaminated, and the ICU ventilator circuit uncapped and reconnected.

7. The ETT clamp is then removed. 8. This procedure is considered interim, and may change in the event of significant

surge and scarcity of ICU nursing resources.

Airway Management during Cardiac Arrests Intubated Patient

1) Do not enter the room unless full airborne precaution PPE is worn 2) Keep the patient on the ICU ventilator 3) Increase fiO2 to 1.0 4) Ignore/pause the alarms 5) Do NOT clamp the ETT with chest compressions in progress - severe barotrauma risk 6) When ETT clamp is ready, briefly pause CPR 7) Turn off ventilator 8) Clamp ETT 9) Disconnect ventilator 10) Attach BMV assembly 11) In case of copious secretions (eg aspiration, APO) clamp the ETT, remove BMV with

filter, attach inline suction, then re-attach BMV with filter and capnograph)

Non-intubated patient 1) Do not enter the room unless full airborne precaution PPE is worn 2) Chest compressions only until airway (ETT or LMA) is established 3) early if not immediate LMA or intubation

Safe Extubation

• Complete Standard RMH ICU extubation checklist • Patients should ideally be ready for extubation onto facemask. • NIV and HFNO should be avoided where possible. • Two staff members should perform extubation. • The same level of PPE should be worn for extubation as is worn by the Airway • Operator, Airway Assistant and Team Leader during intubation. • The patient should not be encouraged to cough. • A simple oxygen mask should be placed on the patient immediately post extubation to • minimise aerosolization from coughing. • Oral suctioning may be performed, with care taken not to precipitate coughing.