There are many complicated guides on airway management and protected intubation since the COVID-19 pandemic broke. This can be confusing in our rush to develop protocols and guides in our own EDs. In this podcast, part of the COVID-19 EM Cases 5-part series, we aim to simplify protected intubation so that you can adapt it to your ED rapidly. Canada’s leading airway expert, George Kovacs guides us through the general principles and important details of the protected RSI…
Podcast production, sound design & editing by Anton Helman
Written Summary and blog post by Anton Helman March, 2020
Cite this podcast as: Helman, A. Kovacs, G. Episode 140 COVID-19 Part 4 – Protected Intubation. Emergency Medicine Cases. March, 2020. https://emergencymedicinecases.com/covid-19-protected-intubation. Accessed [date]
This podcast and blog post are based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.
This podcast was recorded on March 19th, 2020 and the information within is accurate up to this date only, as the COVID pandemic evolves and new data emerges. The blog post will be updated regularly and we are working on a weekly update via the EM Cases Newsletter which will be replicated on the EM Cases website under ‘COVID-19’ in the navigation bar.
COVID-19 oxygenation algorithm and indications for intubation
Update April 2nd, 2020 Oxygenation Strategies on REBELEM
Update 2021: Multi-center ED and ICU randomized control trial assessing “first pass” intubation success rate with either bougie first (n=566) or endotracheal tube (ETT) and stylet (n=546). No difference between both groups in first pass success rate across mix of providers (residents, ED attendings, and ICU). Abstract
Medications for protected intubation to be drawn up outside room
Norepinephrine infusion (0.1 mcg/kg/min infusion started 16 mcg/ml mix)
Bolus dose rescue pressor (Epinephrine 5-20 mcg; Phenylephrine 50-200 mcg; Norepi 8-16 mcg= 0.5-1 ml of 16 mcg/ml infusion mix in 3cc syringe)
Consider glycopyrolate 0.2 mg IV (to help minimize ketamine-related secretions)
Adapted from “A pandemic airway checklist: the basics of how to potentially increase safety during intubation, donning, and doffing” by Brindley, P, Mosier, J and Hick, C.
Passive Pre-oxygenation *NO BAGGING
Update April 5th, 2020 Preoxygenation video with George Kovacs
*Use the lowest flow necessary to achieve an oxygen saturation of 90%
*Have a dissociative dose of ketamine ready to give slowly during pre-oxygenation as per delayed sequence intubation for uncooperative patients.
Nasal prongs (NP) 5L max
Non-rebreathing Mask (NRB) 15L max (Tavish or HiOx see image)
BVM + PEEP valve + viral filter + flex mount + waverform CO2 at 15L O2, 10cm PEEP
NRB options for protected RSI and respiratory management
Update March 29th: We know that BVM can aerosolize virus particles, especially when bagging (which is generally not recommended in the COVID era), however BVM is recommended as an option for pre-oxygenation and re-oxygenation after a failed first attempt. A key aspect of the technique to minimize the chances of aerosolization is the type of grip. The “CE” grip is the one handed grip which is not recommended and the “VE” 2-handed grip (with aggressive jaw thrust and the thenar eminences almost touching) is recommended (see image).
Left: “CE” one handed grip not recommended. Right” 2 handed “VE” grip with thenar eminences almost touching is recommended for BVM in the protected RSI
Update April 1st, 2020 George Kovacs video on 2 handed VE grip VIDEO
The protected intubation
Primary intubation device: Macintosh video laryngoscopy with bougie
Storz C-MAC® S with single-use Macintosh 3 or 4 blades;
GlideScope ® Spectrum™ with single use [Macintosh-shaped] DVM 3 or 4 blades;
McGrath Mac with single-use Mac size 3 or 4 blades.
If no Macintosh device is available, use hyperangulated video laryngoscopy.
*Using a conventional out-of-package (straight to coudé tip) bougie is not recommended as an adjunct with hyperangulated video laryngoscopy. In experienced hands, a ‘customized’ distally bent bougie, a purposeful made malleable or steerable bougie may be used with hyperangulated video laryngoscopy.
Note that you won’t see an ETCO2 trace unless you gently provide pressure support. Anytime you squeeze the bag there is some risk to aerosolization. The risk of controlled ventilation (6-10 breaths over 1 minute) must be balanced against worsening hypoxemia that results in cardiac arrest.
Place an oral airway and apply your filtered BVM system with 10cm PEEP, 15 LO2 with manual breaths (6-10 over 1 minute). Having a pressure manometer attached to the MDI port to avoid pressures >15 is ideal.
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Luo M, Cao S, Wei L, et al. Precautions for Intubating Patients with COVID-19. Anesthesiology 2020;1.
Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;395(10223):507–13.
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Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed sequence intubation: a prospective observational study. Ann Emerg Med 2015;65(4):349–55.
Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation. JAMA 2018;319(21):2179.
Drs. Helman and Kovacs have no conflicts of interest to declare
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.