Intubation Video Instruction for Novel Respiratory Viruses

 

Created by the ICU Group, Health Sciences North in Sudbury, Ontario

1. Equipment Required for Intubation

  • Non-rebreather (NRB)

    • Ideally with filter or consider applying a surgical mask​

  • Avoid Bag-Mask Ventilation if possible​

    • Risk of aerosolizing particles​

    • PEEP valve & BMV once patient safely intubated

  • Video laryngoscopy recommended​

  • ETT, stylet of choice (rigid or flexible)

  • In-line suctioning apparatus

  • Atraumatic clamp for clamping ETT

  • Suction

Equipment Required for Intubation

2. Ventilator Set-Up

  • Key principle: minimize opening vent circuit to avoid aerosolizing the virus

  • Humidified circuit chosen here to avoid need to open circuit to change HME filter

  • If humidified circuit is not available, use a regular circuit with HME filter and put a bacterial-viral filter in line on the patient side of the Y, closest to the patient. Then, when the circuit is open the filter is in place closest to the patient. 

  • Extra bacterial-viral filters placed on inspiratory & expiratory limbs

Ventilator Set-Up

3. Portable Ventilator Set-Up

  • Note the bacterial-viral filter after the HME filter, before the Y

  • A second bacterial-viral is in place closest to the ventilator

Portable Ventilator Set-Up

4. Pre-Oxygenation Options

  • Consider applying a surgical mask to minimize droplet exposure, and a Non-Rebreather (NRB) mask on top

  • If available, use a NRB mask that has a built-in filter that is used with Mucomyset administration to possibly minimize droplet exposure

  • Avoid Bag Mask Ventilation, if possible to avoid aerosolizing viral particles

Pre-Oxygenation Options

5. Intubation Set-Up

  • All intubations should be done in negative pressure rooms

  • Minimize the number of staff in the room

    • Experienced intubator​

    • RT or helper

    • RN - drug administration

    • Runner outside the room

  • Enhanced Personal Protective Equipment (PPE)​

Intubation Set-Up

6. Intubation Procedure

  • Video laryngoscopy

  • Rapid Sequence Intubation (RSI) to avoid coughing or vomiting which can increase staff exposure of aerosolized particles

  • Clamp ETT whenever possible with an atraumatic clamp to avoid aerosolizing particles or damaging the ETT. Use caution while clamping if the patient is not paralyzed (very brief clamping) for patient safety

Intubation Procedure

7. Confirming ETT Placement

  • We recommend not using stethoscopes in the room at any time to avoid contamination of staff

  • ETT placement can be confirmed with an in-line CO2 detector and optional ultrasound confirmation of bilateral lung sliding (if available and staff trained)

  • A delayed chest x-ray after intubation and any other procedures (NG placement, central line, etc.) can be done to confirm everything at once

  • Again, clamp ETT before opening circuit to remove CO2 detector

Confirming ETT Placement

8. Maintaining a Closed Circuit

  • Clamp ETT during circuit changes

    • Use an atraumatic clamp (to preserve ETT)​

    • Use caution if the patient is not paralyzed (clamp, change circuit and unclamp quickly)

  • Avoid nebulized bronchodilators​

  • Avoid MDI bronchodilators, even through the small port, because opening even these small ports can aerosolize viral particles

9. Discarding of Contaminated Equipment

  • Consider using a basin to discard the intubation supplies in one location

  • Consider wiping down the immediate area with approved disinfectant with anti-viral properties prior to moving patients from the negative pressure isolation room to the droplet isolation room

Discarding of Contaminated Equipment

10. Tips for Keeping the ETT connector on

Discarding of Contaminated Equipment

Stay Safe & Informed

These videos were created with the best available literature, local equipment and expertise. It is intended as a guide to maintain patient and staff safety. As more information becomes available, intubation safety practices may change. 

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