| Key principles |
- Maximize first-attempt success while keeping patients and providers safe.
- Prevent contamination and spread of virus. There is a high risk of aerosolization of virus during airway management.
- Tracheal intubation should be performed by the clinician with the most airway management experience whenever possible.
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| RSI steps (seven P's) | Important actions and modifications |
| Preparation | - Use checklist adapted for COVID-19 patients. Placing required airway equipment and medications in prepackaged bundles may be helpful.
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- Review airway plan as a team before entering room. RSI preferred whenever possible. Avoid awake intubation (cough during awake intubation increases viral spread).
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- Prepare all required equipment and draw up and label all medications (including induction agent, NMBA, vasopressor [eg, norepinephrine infusion], isotonic IVF) before entering intubation room.
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- Keep all nonessential equipment just outside room.
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- Have available all standard airway equipment plus:
- Bag-mask with HEPA filter
- Video laryngoscope with clear, disposable cover for the device
- Ventilator and tubing with in-line adaptors (for suctioning and bronchoscopy) and HEPA filters
- Waveform capnography if available
- Smooth clamp for ETT
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- Use negative-pressure room for intubation whenever possible. Keep door closed; may hang a sign prohibiting entrance during procedure.
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- Limit intubation team in room to 3 members: intubator; nurse or other clinician; respiratory therapist.
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- If possible, second intubator wearing PPE should remain outside room to assist with anticipated difficult airway or as necessary.
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- Before entering room:
- Perform hand hygiene.
- Don PPE with proper technique and supervision. PPE should include:
- N95 respirator or PAPR
- Eye protection (goggles, face shield that covers front and sides of face, or full face PAPR)
- Double gloves
- Gown and cap (some recommend shoe covers, such as disposable booties)
- Prepare marked bags for proper disposal/removal of clothing and equipment.
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- The precautions against infection listed immediately above should be taken by all clinicians directly involved in any pediatric intubation or airway management. Asymptomatic infection in children is common and poses a risk for disease transmission.
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- Avoid pretreatment with nebulizers if possible; use MDI instead.
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| Preoxygenation | - Preoxygenate patient for 3 to 5 minutes with 100% O2 using low or moderate flow rates (10 to 15 L/minute) and NRB mask. Avoid BMV if at all possible. 5 minutes of preoxygenation preferred if circumstances permit.
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- If needed, can preoxygenate with modified NIV by using tightly fitting, non-vented mask connected to closed-circuit, dual-limb ventilator with HEPA filter. Use a full-face mask if available (reduces aerosolization). Mask must fit standard ventilator tubing. Continue NIV until patient apneic. Suspend ventilator before removing mask for intubation.
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- If patient remains hypoxic (SpO2 <93%) using NRB mask, and NIV with closed circuit not available, can use BMV with HEPA filter and PEEP valve. Hold mask tightly on patient's face using 2-hand thenar technique, increase oxygen flow rate as needed, and have patient breathe passively. Perform synchronized bag-assist ventilation only if required.
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- In the hypoxic, agitated patient who cannot cooperate with preoxygenation efforts, a reasonable approach is to sedate the patient with a smaller dose of ketamine (eg, 0.5 mg/kg IV) than would be used for RSI. This dose generally preserves spontaneous ventilation and enables the patient to tolerate a tight mask seal, which may improve oxygenation and reduce viral shedding. Once preoxygenation is complete, RSI may be performed using the remaining dose of ketamine or another induction agent and a NMBA.
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- Avoid high-flow oxygenation methods (eg, flush rate) unless clinically required.
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- Avoid nasal cannula for oxygenation, including apneic oxygenation.
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- Upright posture or reverse Trendelenburg positioning improves preoxygenation.
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- Avoid BMV if at all possible; use HEPA filter if BMV must be performed.
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- If BMV necessary, 2-person thenar technique gives better seal and reduces aerosolization/contamination risk (provided entry of additional provider can be avoided). Provide BMV using low volumes and relatively high rates.
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| Pre-intubation optimization | - May give IV fluid bolus prior to giving RSI medications to patients who are volume depleted.
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- Avoid high-volume fluid resuscitation in COVID-19 patients at risk for ARDS.
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- Push-dose pressor may be needed for patients at high risk for hemodynamic decompensation (options include phenylephrine 100 micrograms IV or epinephrine 10 micrograms IV).*
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- Vasopressor (eg, norepinephrine) infusion may be needed for patients with hypotension or hemodynamic instability before or following administration of RSI medications.
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| Paralysis with induction | - Use high-dose NMBA: rocuronium 1.5 mg/kg IV or succinylcholine 2 mg/kg IV. Goal is rapid-onset apnea and elimination of cough.
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| Protection of patient and staff | - Refer to "Preparation" above and "Post-intubation management" below.
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| Placement (intubation) | - Use video laryngoscopy whenever possible.
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- Performed by experienced intubator.
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- Supraglottic airway preferred for rescue oxygenation and ventilation if needed (eg, intubation difficulty).
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- Ensure ETT is inserted 19 to 22 cm (measured at teeth); may reduce need for confirmation by chest radiograph.
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| Post-intubation management¶ | - Inflate cuff immediately following ETT placement and prior to initiating PPV.
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- Confirm placement of the ETT. If a colorimeter or other removable EtCO2 detector is used, clamp the ETT before removing the device.
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- After confirming ETT placement, clamp the ETT, connect the ventilator tubing, and then remove the clamp. HEPA filter between ETT and ventilator should be in place. Start mechanical ventilation. Secure the ETT.
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- Ventilator settings suitable for patient with ARDS are likely to be needed (assuming COVID-19-related respiratory illness is reason for intubation).Δ
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- Procedure bundles can reduce exposure. May choose to perform intubation and central venous catheter placement together and then obtain portable chest radiograph to assess both.
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- Limit ventilator disconnections. When disconnection required, clamp ETT first and disconnect at end-expiration.
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- Ideally, use ETT and ventilator with in-line adaptors for suctioning and bronchoscopy.
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- Ensure adequate sedation for patient care and safety and to avoid accidental extubation or disconnection of tubing.
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- Bag, transport, and clean all equipment as required.
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- Use proper PPE doffing, supervised by coach or other team member. Once PPE is removed, thoroughly clean your hands and any exposed skin on the neck and face.
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