Airway Management and Preparation for COVID19 Patients
The guidance and recommendations made by CMS, CDC and Specialty organizations is constantly evolving. Many of the changes that occur are from the difficult lessons learned from our overseas colleagues.
In China, 4% of patients required mechanical ventilation i.e. required intubation.
Intubation of an infected patient is a risk to healthcare workers and a recent Australasian consensus statement helps to minimize cross infection from droplet/aerosol generation during airway management.
Key points include:
Wear Personal Protective Equipment (PPE)
Disposable airway equipment is always preferred
Endotracheal intubation is the best option
Use a 2nd generation supraglottic device if used as higher seal pressures may reduce the risk of aerosolization of the virus
Video laryngoscopy is not available everywhere but those devices with disposable blades are recommended
Avoid close contact with the patient’s mouth
First Pass Success minimizes the risk of aerosolization of the virus
While preparing for the large influx of patients, maintenance of ventilator capacity, preservation of PPE and staff safety, the CDC on March 18th, 2020 made the following recommendations re ambulatory care:
Delay all elective ambulatory provider visits
Reschedule elective and non-urgent admissions
Delay inpatient and outpatient elective surgical and procedural cases
Postpone routine dental and eyecare visits
Additionally on March 20th, the Academy of Otolaryngology – Head and Neck Surgery, through diligent research by Stanford Medicine and others have identified ENTs (Otolaryngologists) as one of the highest risk groups to contract the virus alongside ophthalmologists and neurosurgeons who perform transnasal procedures. Please note that the greatest density of COVID19 is within the nose and nasopharynx.
The Academy suggests extreme caution when advising procedures or surgery occurring through a transnasal or trans-oral route unless necessary as close proximity and performing procedures within the nose and mouth facilitates transmission of the COVID19 virus.
Intubation carry’s significant risk to the individual performing the procedure as well as those in close proximity. The risk of contracting the disease may be higher in less than ideal circumstances, including the pre-hospital setting or in high risk patient populations such as obese patients.
First Pass Success rates during endotracheal tube placement in the United States pre-hospital setting is 53%. The remaining 47% of cases require 2 or more attempts at intubation. Multiple attempts, time required to intubate, and changes in equipment used may increase the likelihood of viral contamination.
Many services do not have access to a video laryngoscope. Secondary, providers may lack the necessary experience to achieve intubation on the first attempt.
The Adroit Surgical Team is here to help. We’re training and engaging in Q&A sessions via web video calls, but also will address any requests or questions via email or phone