Airway Management in Pandemic

(COVID-19)
Pembimbing: dr. M. Helmi, Sp.An., KIC, M.Sc., MARS, FISQua
Oleh : Regina Theodora (406182093)
Pute Ayu (406182099)

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 Background
An outbreak in Wuhan, China, in 2019 of the novel Coronavirus has led to a pandemic of
COVID-19 disease. More than 80% of confirmed cases report a mild febrile illness, however,
17% of confirmed cases develop severe COVID-19 with acute respiratory distress syndrome
(ARDS): 4% requiring mechanical ventilation and 4% having sepsis. Like other patient groups
with ARDS, patients with severe COVID-19 are likely to be considered for emergency tracheal
intubation and mechanical ventilation to support potential recovery from their illness.
From recent reported data in Wuhan and Northern Italy, at least 10% of reported positive
COVID-19 cases require ICU involvement, many requiring urgent tracheal intubation for
profound and sudden hypoxia.

Huang C, Wang Y, Li X et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020; 395: 497–506
Kepaniteraan Klinik Ilmu Anestesi
Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
High consequence infectious diseases (HCID). Accessed March 10, 2020 at https://www.gov.uk/guidance/high-consequence-
infectious-diseases-hcid

Risks to healthcare workers

Aerosol generation during airway management
Aerosol generating events
• Coughing/sneezing
• NIV or positive pressure ventilation with inadequate seal*
• High flow nasal oxygen (HFNO)
• Delivery of nebulised/atomised medications via simple face mask
• Cardiopulmonary resuscitation (prior to intubation)
• Tracheal suction (without a closed system)
• Tracheal extubation
Procedures vulnerable to aerosol generation
• Laryngoscopy
• Tracheal intubation
• Bronchoscopy/Gastroscopy
• Front-of-neck airway (FONA) procedures (including tracheostomy,
• cricothyroidotomy)

*The reliability of seal is greatest with tracheal tube>supraglottic airway>face mask

Kepaniteraan Klinik Ilmu Anestesi
Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
High consequence infectious diseases (HCID). Accessed March 10, 2020 at https://www.gov.uk/guidance/high-consequence-
infectious-diseases-hcid

Risk factors for aerosol generation

Risk Factor Protective Strategy
Coughing • Full PPE before entering intubation room and getting in close
proximity to patient’s airway.
• Minimise interval between removal of patient’s PPE and application
of face mask with viral filter
• Good seal with face mask with viral filter
• Ensure profound paralysis before instrumenting airway (adequate
dose and time for effect).

Inadequate face mask seal during pre- oxygenation
• Well-fitting mask with viral filter
• Vice (V-E) grip
• Manual ventilation device with collapsible bag*
• ETO2 monitoring to minimise duration for which face mask applied
by identifying earliest occurrence of adequate pre-oxygenation.

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
High consequence infectious diseases (HCID). Accessed March 10, 2020 at https://www.gov.uk/guidance/high-consequence-
infectious-diseases-hcid

Risk factors for aerosol generation

Positive Pressure Ventilation with inadequate • Avoid PPV
seal • Good seal:
FM: as above
SGA: appropriate size, adequate depth of insertion, cuff inflation**
ETT:confirmcuffbelowcords,cuffmanometry, meticulous securing of ETT.
Manual ventilation device with collapsible bag to gauge ventilation
pressures*
Airway manometry to minimise ventilation pressures**
Minimise required ventilation pressures: paralysis, 45-degree elevation,
oropharyngeal airway.

High gas flows Avoid HFNO, nebulisers and airway suction with an open system

*Only beneficial for clinicians with prior familiarity with these devices.
**Where available
Kepaniteraan Klinik Ilmu Anestesi
Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 Guiding principles for airway
management of COVID-19
patients
1. Intensive Training
2. Early intervention
3. Meticulous planning
4. Vigilant infection control
5. Efficient airway management processes
6. Clear communication
7. Standardised practice

Brewster D, Chrimes N, Do T et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult
patient group. The Medical Journal Of Australia. New Zealand.2020

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 Efficient airway management processes in the
COVID-19 groups
1. Environment for airway management
2. Equipment, Monitoring and Medications
3. Team
4. Planning
5. Communication
6. Cognitive Aids
7. Personal Protective Equipment (PPE)
8. Process for Airway Management
9. Education
10. Special Contexts
Brewster D, Chrimes N, Do T et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult
patient group. The Medical Journal Of Australia. New Zealand.2020

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 Brewster D, Chrimes N, Do T et al. Consensus statement: Safe Airway Society
principles of airway management and tracheal intubation specific to the COVID-19
adult patient group. The Medical Journal Of Australia. New Zealand.2020

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 Brewster D, Chrimes N, Do T et al. Consensus statement: Safe Airway Society
principles of airway management and tracheal intubation specific to the COVID-19
adult patient group. The Medical Journal Of Australia. New Zealand.2020

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 PPE – What to Wear
•N95 (PAPR if bearded)
•Surgical Mask over N95
•Goggles that surround eyes with facial contact, face shield, or full
joint-replacement-hood with visor (full face coverage desperately
preferred)
•Bunny suit, preferably with hood or disposable fluid-proof gown
•Something to cover your neck if not in hood
•If no hooded suit available, disposable cap
•2 pairs gloves, 1 under sleeves of bunny suit or gown and 1 over,
under-layer gloves would ideally be long cuffed
•Booties are a big doffing risk, so wear shoes you can disinfect

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 Management of severe COVID-19: oxygen therapy and monitoring
Give supplemental oxygen therapy immediately to patients with SARI and respiratory
distress, hypoxaemia or shock and target > 94%

Remarks for adults:

• Adults with emergency signs (obstructed or absent breathing, severe respiratory distress, central
cyanosis, shock, coma or convulsions) should receive airway management and oxygen therapy
during resuscitation to target SpO2 ≥ 94%
• Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥ 93% during
resuscitation; or use face mask with reservoir bag (at 10–15 L/min) if patient in critical condition
• Once patient is stable, the target is > 90% SpO2 in non-pregnant adults and ≥ 92–95% in pregnant
patients

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 Remarks for children:

• Children with emergency signs (obstructed or absent breathing, severe respiratory distress, central
cyanosis, shock, coma or convulsions) should receive airway management and oxygen therapy during
resuscitation to target SpO2 ≥ 94%; otherwise, the target SpO2 is ≥ 90%
• Use of nasal prongs or nasal cannula is preferred in young children, as it may be better tolerated

All areas where patients with SARI are cared for should be equipped with pulse oximeters, functioning
oxygen systems and disposable, single-use, oxygen-delivering interfaces (nasal cannula, nasal prongs,
simple face mask and mask with reservoir bag)

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 Closely monitor patients with COVID-19 for signs of clinical deterioration, such as rapidly
progressive respiratory failure and sepsis and respond immediately with supportive care
interventions.

Patients hospitalized with COVID-19, require regular monitoring of vital signs and, where possible,
utilization of medical early warning scores (e.g. NEWS2) that facilitate early recognition and
escalation of the deteriorating patient

Haematology and biochemistry laboratory testing, and ECG should be performed at admission and
as clinically indicated to monitor for complications, such as acute liver injury, acute kidney injury,
acute cardiac injury or shock. Application of timely, effective and safe supportive therapies is the
cornerstone of therapy for patients that develop severe manifestations of COVID-19

After resuscitation and stabilization of the pregnant patient, then fetal well-being should be
monitored
Kepaniteraan Klinik Ilmu Anestesi
Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 Understand the patient’s co-morbid condition(s) to tailor the management of critical illness

Determine which chronic therapies should be continued and which therapies should be stopped
temporarily. Monitor for drug-drug interactions.

Use conservative fluid management in patients with SARI when there is no evidence of shock

Patients with SARI should be treated cautiously with intravenous fluids, because aggressive fluid
resuscitation may worsen oxygenation, especially in settings where there is limited availability of
mechanical ventilation. This applies for care of children and adults

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 COVID intubation pack
• Place in Large X-ray Ziplock Bag Adult BVM
• Face-Shield/Knights Helmet or Hood
• Multi-purpose Adaptor
• Oxygen Tubing
• ETCO2 Adaptor
• ETCO2 Tubing
• Yellow Viral Filter Besides the pack, you will
need intubation meds, a video
• ETAD Tube Securement laryngoscope and either a medium or
• In-Line Suction large (depending on patient) non-
vented bipap mask
• Flex Tip Bougie
• PEEP Valve
Kepaniteraan Klinik Ilmu Anestesi
Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 Intubation strategy
•Make a cell phone call to a buddy who will stay • Highest-Level Physician (attending level) should
outside the room and then put your phone on do the Intubation
speaker in your chest pocket to allow continuous
communication • Use CMAC or Glidescope with new bougies to
maximize 1-attempt success
•RSI with high-dose paralytic, ketamine is preferred • Visualize black line of ETT at level of cords to
induction b/c if patient is not compliant with preox, avoid having to auscultate for depth
perform immediate ketamine dissociation for DSI
• Cuff fully inflated and viral filter on the ETT prior
•BVM or Vent for Reoxygenation (only if needed!) to bagging/hooking to vent
with viral filter at the wye of vent or stem of BVM,
can be by mask or LMA. EtCO2 monitoring should • Confirm with ETCO2, not auscaltation
be behind the viral filter to allow monitoring of
mask/LMA seal, both for REOX efficiency and team
safety—i.e. a crappy seal puts you and the patient
at risk. (best option is apneic CPAP reoxygenation)

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020
 References
1. Huang C, Wang Y, Li X et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
Lancet. 2020; 395: 497–506
2. Chen N, Zhou M, Dong X et al. Novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet Adv.
2020; 29 https://doi.org/10.1016/S0140-6736(20)30211-7
3. High consequence infectious diseases (HCID). Accessed March 28, 2020 at
https://www.gov.uk/guidance/high-consequence-infectious-diseases-hcid
4. Brewster D, Chrimes N, Do T et al. Consensus statement: Safe Airway Society principles of airway
management and tracheal intubation specific to the COVID-19 adult patient group. The Medical Journal Of
Australia. New Zealand.2020. Accessed March 28, 2020 at
ttps://www.mja.com.au/journal/2020/212/10/consensus-statement-safe-airway-society-principles-airway-
management-and
5. Weingart S. COVID Airway Management Thoughts. Accessed March 29, 2020 at
https://emcrit.org/emcrit/covid-airway-management
6. WHO. Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease is
Suspected. Accessed March 29, 2020 at
https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-no
vel-coronavirus-(ncov)-infection-is-suspected
 Terima Kasih
Atas Perhatiannya

Kepaniteraan Klinik Ilmu Anestesi

Fakultas Kedokteran Universitas Tarumanagara Periode 30 Maret – 4 April 2020