Episode 12: Airway Management in the Era of COVID-19

Episode Summary

First and foremost, we want to thank all the CRNAs, nurses, technicians, MDs, housekeeping personnel, and front-line providers who provide care in both the prehospital and hospital environments. Your sacrifices and commitment are truly heroic. All of us at APEX Live have enormous respect for you and wish you safety and good health as we move forward during this crisis.

In this episode of the APEX Live Anesthesia Podcast, we talk about intubating the patient with suspected or confirmed COVID-19 infection. We talk about how to prepare safely using personal protective equipment and discuss the current protocols clinicians are using to conduct airway management.


What You'll Learn

  • What are the ways that COVID-19 can be transmitted during airway management?
  • How does someone prepare to manage an airway with suspected/confirmed COVID-19?
  • What are the recommendations for intubation with someone with suspected/confirmed COVID-19?
  • How should we manage COVID-19 patients immediately after airway management and on the ventilator?
  • How should we manage routine airways in the OR?


Process for Donning PPE

  1. Place shoe covers.
  2. Wash hands thoroughly.
  3. Put on 1st pair of gloves.
  4. Put on a waterproof gown.
  5. Place an N95 mask with a surgical mask over the top.
  6. Place goggles or face shield.
  7. If PAPR available, you can use this in place of N95 and googles.
  8. Place 2nd & 3rd pair of gloves.  


Preparation for Intubation

  1. Communicate with RN about a patent IV line, available suction, & equipment (including ventilator or transport ventilator with filter and restraints).
  2. Have RN/RT place the patient on a nonrebreather mask and optimize patient positioning & bed for intubation.
  3. Communicate airway plans with the medical team and confirm that all airway equipment is immediately ready & available.
  4. Draw up medications for intubation.
  5. Discuss post-intubation sedation or if the patient is stable enough to be transferred to ICU for intubation (if on a med surg floor). Have monitors hooked up & ready to go before intubation.
  6. Remove all unnecessary equipment from the provider & the video laryngoscope.
  7. Don PPE (as indicated above).


Airway Management Highlights

  1. Assure there is at least 1-2 medical personnel available with appropriate PPE to help with airway management.
  2. Preoxygenate the patient under plastic drape with anesthesia mask or BVM. Place a viral filter between the mask and the y-piece. Hold the mask with two hands to ensure a tight seal.
  3. Perform a rapid sequence intubation.
  4. Use a videolaryngoscope (VL) and intubate under the plastic drape.
  5. Confirm ETT placement with VL and consistent EtCO2. Avoid using a stethoscope.
  6. Maintain the viral filter between the airway device and the y-piece. Another filter should be placed between the expiratory limb and the anesthesia machine.
  7. If positive ventilation needed during intubation, consider using a supraglottic airway device (i.e., LMA supreme) with a viral filter.


Process for Doffing PPE

  1. Consider doffing with someone watching you (to ensure good technique). If this isn't possible, doffing in a mirror may be helpful.
  2. Removed the outer pair of gloves if soiled.
  3. Wash your hands with alcohol-based hand sanitizer.
  4. Remove gown taking care to avoid touching the front and sleeve portion of gown, and remove shoe covers.
  5. Remove the outer pair of gloves.
  6. Wash hands with alcohol-based hand sanitizer before removing anything from the face.
  7. Remove face shield or goggles by grabbing the back of the strap and placing reusable material in a receptacle.
  8. Remove an N95 mask by handling the straps behind your ears and never touch the front of the mask (place in designated receptacle if reusable).
  9. Remove the inner gloves.
  10. Wash hands thoroughly.
  11. Consider changing scrubs if contaminated and wash any part of your body that could have been exposed.


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Recommended Resources

  1. Scott Weingart. EMCrit 268 – COVID Airway, Cardiac Arrest, Some Ethical Questions, etc.. EMCrit Blog. Published on March 19, 2020. Accessed on March 24th 2020.

  2. EMCrit COVID Airway Management Thoughts

  3. REBEL EM COVID 19 Airway Management

  4. ACCRaC Airway Management

  5. Three steps to intubate safely with COVID-19

  6. HIPPO Education (ERCast)

  7. What if I get called in?

  8. AANA clinical practice resources

  9. EMCrit Internet Book of Critical Care – COVID-19 


Legal Disclaimer

APEX Anesthesia Review, LLC and APEX Live expressly disclaim any liability in connection with the use of any content in its podcasts, social media posts, and all other published content by any third party.

Podcast music by Eino Toivanen, kongano.com


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