Posted by American Heart Association on Apr 14th 2020

AHA New Guidelines for Oxygenation and Ventilation of COVID-19 Patients Released April 9, 2020 Oxygenation and Ventilation of COVID-19 Patients Module 2: Airway Management

AHA New Guidelines for Oxygenation and Ventilation of COVID-19 Patients Released April 9, 2020 

Oxygenation and Ventilation of COVID-19 Patients Module 2: Airway Management

Objectives 

• To review criteria of when to intubate 

• To review an inventory of items needed to successfully perform an intubation of those with or suspected of having      COVID-19 

• To discuss risk mitigation techniques specific to COVID-19 used to protect healthcare providers 

• To review manual

Escalation to invasive ventilation

• There are several reasons to consider intubation in COVID-19 patients 

• If using HFNC of 40 or greater, use the ROX Index to determine when to intubate 

• ROX Index = (SpO2/FIO2) / respiratory rate 2 Hours 6 Hours 12 Hours <2.85 <3.47 <3.85 

• If using NIV and an FIO2 >0.6 cannot maintain a SpO2 >90% 

• General on any noninvasive modality 

• Septic shock 

• Worsening oxygenation PaO2/FIO2 or SpO2/FiO2 <150 

• Hypercapnia/acidosis with a pH <7.3 

• High work of breathing 

• Altered mental status attributed to respiratory failure ventilation devices and filter placement

Sample supply list 

These supplies should be taken in addition to, not instead of, the arrest bag to all intubations/arrests of patients under investigation (PUI)/confirmed COVID-19 cases

  • High-efficiency particulate air (HEPA) filter 
  • N95 masks × 4 (2 small, 2 regular) 
  • Full face shield (welder mask) × 2 preferred (surgical face shields × 2 if no welder mask available) 
  • McGrath, 3 blade × 2, 4 blade × 2 (if not in the standard arrest bag) 
  • Isolation gown × 2 (yellow, not waterproof) 
  • Waterproof (blue) gown × 2 
  • Sterile gown × 1 if available 
  • Bouffant hat × 2 
  • Long “beard” hat × 1 (Note: Beards will interfere with the effectiveness of the N95!) 
  • Sterile gloves: 6.0, 6.5, 7.0, 7.5 
  • Bag for McGrath Handle/battery post-intubation
    • Do not need to be taken to non–COVID-19 intubations/arrests 

    Do not take the COVID/arrest bag into the room with PUI/confirmed COVID-19 patient 

    Take only the things that you need with you into the room 

    Prepare medications and intubation equipment outside of the patient’s room 

    Have a dedicated provider outside the room to hand any necessary additional equipment/medications to avoid contaminating the bag 

    If the bag is contaminated, discard all disposable items; clean nondisposable items with wipes (follow manufacturer’s directions) 

    Do not forget to restock at the end

    Things that may be different 

    N95 mask/personal protective equipment (PPE) + eye protection 

    Beards or not being fit tested for N95 masks decrease effectiveness 

    Rapid sequence intubation with video laryngoscope performed by the most experienced provider 

    Heat moisture exchange/filter 

    Prolonged mask ventilation and following intubation 

    HEPA filter on manual ventilation devices and ventilators 

    Roll of tape/manufacturer holder per patient 

    Other items to reduce aerosol generation 

    After intubation, use in-line suction catheters 

    Disconnect the endotracheal tube (ETT) as few times as possible

    CPR in COVID-19 

    Ensure hand hygiene and PPE for resuscitation team before entering the room 

    Goal is early intubation 

    Minimize bag-mask ventilation; if necessary 

    2-hand masking to ensure a tight seal by the most experienced provider, with second provider assist with bag ventilation 

    HEPA filter between mask and bag 

    If unable to intubate via trachea, consider placing laryngeal mask airway (LMA) for ventilation 

    Hold chest compressions while intubating to minimize aerosolization of the virus and infectious risk to resuscitation team 

    Clearly alert code leader and team members providing chest compressions

    Continued risk mitigation: 

    Cleaning 

    Disposable devices should be discarded within the room and processed by housekeeping according to procedure 

    Items that are reusable should be processed according to policy 

    This usually requires at minimum a 2-step process of cleaning and then disinfection; disinfection usually requires a 2- to 5-minute dry time 

    If supplies of HEPA filters is a concern, typically a single HEPA filter can be used for 2 purposes