Mitigation of COVID-19 exposure during intubation of a patient with a difficult airway

ABSTRACT

Introduction: The Society of Critical Care Medicine (SCCM);endorse early intubation for COVID-19 patients with a FiO2 of greater > 0.40. Bag mask ventilation (BMV) is not recommended for fear of aerosol generated particles (AGP) exposure. Personnel protective equipment (PPE), N95 mask and eye protection is mandatory! Before intubation, the patient is administered high concentrations of oxygen to breathe, when the SpO2 increases to greater than > 97%, the advance airway providers (AAP) administers sedation. Once sedated, the AAP will perform a rapid sequence intubation (RSI) and place the patient on mechanical ventilator (MV).Case Review A 41 year old male with a history for hypertension was admitted as a person under investigation (PUI) to a general nursing unit. Laboratory results confirmed that he was positive for COVID-19. He was on a 6 L/min nasal cannula = 0.44 with a SpO2 - 93 to 94% and abnormal breathing;28 to 30 breaths/min. His provider team called to have him intubated. He was administered higher oxygen concentrations to breathe via face mask, his SpO2 increased to 97 - 98%. Sedation was administered. Intubation with a Glide-Scope was attempted;after several failed attempts, SpO2 decreased to < 60%. BMV with a viral filter (VF) was implemented to mitigate provider and environmental exposure. The filter had an efficiency rating of 99.9% for filtering a virus and bacteria, which connected directly onto the resuscitation bag mask. He was successfully ventilated with a resuscitation bag and mask, SpO2 returned to 95-96%. He was successfully intubated;he was then transported to a COVID-19 cohort unit via ventilator with close suction and VF-heat moisture exchanger (HME). Conclusion: Our institutional review team reviewed this case and made modifications to intubate immediately order to consider risk to benefit for stable versus unstable and what actions should be taken into consideration;current location, need for additional staff, equipment and transporting the patient. Additional VF are now a part of standard operating procedure (SOP) for mechanical ventilation transport and available for BMV. Viral filters are important during unexpected airway crisis, especially for patient's diagnosed with COVID-19.