Guidelines for performing endotracheal intubation in patients with COVID-19
| Preparation | Intubation |
| • Hand hygiene • Full PPE per guidelines from CDC; use buddy system • Team member outside room to help (full PPE) • Prepare medications outside room • Have ventilator available in room prior to intubation • Reliable intravenous access • Optimize patient position for intubation • Airway assessment • If difficult airway, have a team capable of performing emergency surgical airway available Equipment needed in room • Endotracheal tube (size 7.5 or 8 mm) with stylet • Video laryngoscope • LMA size 4 • Intubation bougie • Magill forceps • HME/HEPA filter • Capnograph • Suction • Endotracheal tube holder • 10 cc syringe • Fluid bag • Barrier device | • Preoxygenation with 100% non-rebreather mask for 3 to 5 minutes • Do not initiate noninvasive ventilation • Rapid sequence intubation; avoid bag mask ventilation • Attach HME filter immediately after intubation • Avoid auscultation to confirm endotracheal tube position • Confirm tube position with inline capnograph • If difficulty encountered, use supraglottic airway device (LMA) Intubating medications Induction agents a. Propofol 1 to 2.5 mg/kg b. Etomidate 0.2 to 0.3 mg/kg c. Ketamine 1 to 2 mg/kg d. Methohexital 1 to 2 mg/kg Neuromuscular blocking agents a. Succinylcholine 1.0 to 1.5 mg/kg b. Rocuronium 1.2 mg/kg Initial ventilator settings • Pressure-regulated volume control with tidal volume 6 to 8 mL/kg of ideal body weight • Plateau pressure < 30 cm H20 • FiO2 1.0 (FiO2 should be titrated to SPO2 > 92%) • Respiratory rate 12 breaths per minute Postintubation • Doffing per CDC protocol (use buddy system) • Order chest radiograph • Consider placing orogastic tube and invasive lines (eg, arterial and central venous pressure lines) |
CDC = US Centers for Disease Control and Prevention; HEPA = high efficiency particulate air; HME = heat and moisture exchanger; LMA = laryngeal mask airway; PPE = personal protective equipment