Table.

Mayo Clinic Hospital COVID-19 Pandemic Intubation Guideline

Preparation

1. Don appropriate PPE: N95 mask + face shield or PAPR with bonnet, gown, double gloves, and booties, while a team member observes for proper technique.

2. Lean team: only necessary personnel during AGP.

3. Back-up provider with donned PPE outside, in communication with team (eg, speakerphone).

4. Call for help early if a difficult airway is anticipated.

5. Closed-loop, detailed communication of the intubation plan and back-up plan.

a. Prepare equipment for preoxygenation and first intubation attempt.

b. Ensure that back-up equipment is prepared in sealed bag, easily accessible in room.

6. Close the door, and hang “Procedure in Progress” sign during AGP.

Procedure

7. Use an intubation checklist (Adult or Pediatric).

8. Intubation should be performed by an experienced provider.

9. Preoxygenation for 3 to 5 minutes with 100% O2 with tight mask seal and viral filter.

a. Prioritize spontaneous patient breathing, avoiding deep breaths (may cause cough).

10. RSI technique with high-dose paralytic, unless contraindicated.

a. Young children may not tolerate apnea and may require careful mask ventilation.

11. Await full paralysis (45 to 60 seconds) and apnea before removing the preoxygenation device.

12. Video laryngoscopy is strongly preferred (but best device for provider should be used).

a. If performing direct laryngoscopy, maximize the provider face-to-patient face distance.

13. Consider use of early rescue SGA (Air-Q LMA [Salter Labs, Chicago, Illinois] or King LT [Eugene, Oregon]) if first attempt is unsuccessful.

14. Mask ventilate ONLY IF CRITICAL NEED (OPA, tight 2-hand seal, viral filter, low TV breaths).

15. Immediately inflate the ETT cuff (including children) before ventilating patient.

16. Remove outside pair of gloves, and use hand sanitizer on inner gloves.

17. Attach ventilator circuit.

a. Circuit with HME (ETT: in-line suction; HME/filter: capnography device, circuit).

b. Circuit without HME (ETT: in-line suction; capnography device, circuit).

18. Confirmation with visualization, waveform capnography, and bilateral chest rise.

a. When in question, auscultation, colorimetric capnography, or POCUS may be required.

Postprocedure

19. Limit disconnections of the ventilator circuit.

a. Ventilator paused at end expiration, excellent sedation/paralysis, and consider ETT clamp.

20. Dispose of all airway equipment immediately in a predesignated plastic bag.

21. Doff PPE while a team member observes for proper technique, avoiding contamination.

22. After intubation, note time on door when room may be entered without airborne PPE (varies by room and requires air turnover of at least 7 times).

AGP = aerosol-generating procedure; ETT = endotracheal tube; HME = heat and moisture exchanger; LMA = laryngeal mask airway; LT = laryngeal tube; OPA = oropharyngeal airway; PAPR = powered air purifying respirator; POCUS = point of care ultrasound; PPE = personal protective equipment; RSI = rapid sequence intubation; SGA = supraglottic airway; TV = tidal volume.