Coronavirus and Intubation Question

[adventure_rn, MSN, NP]

I have a question regarding intubation and figured I'd ask you folks, the airway experts.

Our hospital policies for COVID-19 isolation have been rolled out, and they repeatedly state that extra precautions need to be taken during "aerosol-generating procedures" including intubation/extubation/bronchs.

I've seen a number of intubations/extubations/bronchs, and I'm having a hard time understanding how those would be any more "aerosol-generating" than a person plain old coughing. Is it because via the disconnected ETT you're creating a direct conduit from their lungs out into the world (whereas they'd usually have the pharynx trapping some of the germs)? It seems to me like you wouldn't need a separate type of isolation just for intubation/extubation/bronch of these patients.

If these procedures are truly 'aerosol-generating,' then should the providers always be wearing masks/face shields when they intubate? In my experience, that definitely isn't standard practice.

Just curious.

[Rose_Queen, BSN, MSN, RN]

I know that the ASA has come out with recommendations, and it's possible that AANA has as well. (I'm an OR nurse, not a CRNA). It's also possible that your facility's anesthesia department has already created guidelines- mine did, but more for required PPE and under what circumstances it's required (positive, presumptive, rule out).

As for difference from "regular" intubations, I'll leave that to the intubation experts.

[NedRN]

I've been trying to wrap my head around the aerosol-generating nature of intubation for a couple of months now since I heard it in a recent ACLS renewal. Not getting it. Nevertheless, in the OR I'm always wearing a mask when I assist intubation.

[MunoRN, RN]

We've wrestled with the same questions, and no, it doesn't make any sense. At the direction of our ID medical director we ignore the CDC's recommendation at least as written, the director's conclusion is that "someone at the CDC doesn't understand how a normal cough works", which is the same conclusion we all came to as well.

Best as we can tell, based on the literature that references "Aerosol Generating Procedures" (AGP), what they are saying is that compared to just normal breathing, an AGP is more likely to produce aerosols. But just based on the basic physiology of a spontaneous cough, ASG's are if anything less likely to produce significant aerosols than a cough does. A normal cough is effectively designed to aerosols; the airway constricts to increase velocity and it oscillates and moves to create turbulence, it's similar to how a spray bottle nozzle works.

We had initially been following the CDC recommendation to use negative air pressure rooms for AGPs and to use PAPRs for these procedures as well. but yet using less aggressive measures with patients with a cough outside of performing these procedures. Really, whatever transmission prevention is worth using during AGP, it's also worth using for patients with a cough.

As a result, we have units and areas of the hospital where the 'coughing COVIDS' are placed, these are whole unit isolation where you use respiratory protection upon entering the unit and keep it on until you leave. Staff don PAPRs or N95s approved for extended use, and just wear it your whole shift; room to room and outside of rooms.

[WestCoastSunRN, MSN, CNS]

Aerosol is certainly produced during IPV treatment and/or with a VDR ventilator, for example. Most patients vented with infiltrates will be receiving these types of modalities. Also, have you ever had the vent tubing disconnect and blow in your face? Positive pressure + warm air = aerosol - as I've experienced it. I agree that I don't understand how just intubating someone would create aerosol. Droplet precautions should be fine for intubation, I would think.

[ProgressiveThinking, MSN, CRNA]

For any patients who are high risk, symptomatic, or confirmed we're wearing PAPR with droplet precautions along with double gloving.

For all other patients we're using N95s and covering it with a surgical mask (to prevent the N95 from becoming soiled in order to reuse), + goggles, double gloves, and yellow gown during intubation. After intubation a surgical mask and goggles only are considered okay. For MAC cases we're being required to wear an N95 mask and observe droplet precautions for the entire case since their airway isn't secured.

We're avoiding LMAs, we're performing RSIs (with succinycholine instead of rocuronium-not sure if it's a cost issue) on everybody and avoiding bag mask ventilation. I'm personally using the Glidescope or some other form of video laryngoscopy on everybody just minimize mouth opening and get the tube in quickly, and during emergence from general anesthesia and extubation, I'm putting my N95 and goggles back on and performing deep extubations on all who don't have any contraindications (A technique where we get the patient breathing spontaneously off of the ventilator while still anesthetized with our volatile agent/gas that prevent patients from bucking and coughing everywhere).

[murseman24, MSN, CRNA]

17 hours ago, ProgressiveThinking said:

For any patients who are high risk, symptomatic, or confirmed we're wearing PAPR with droplet precautions along with double gloving.

For all other patients we're using N95s and covering it with a surgical mask (to prevent the N95 from becoming soiled in order to reuse), + goggles, double gloves, and yellow gown during intubation. After intubation a surgical mask and goggles only are considered okay. For MAC cases we're being required to wear an N95 mask and observe droplet precautions for the entire case since their airway isn't secured.

We're avoiding LMAs, we're performing RSIs (with succinycholine instead of rocuronium-not sure if it's a cost issue) on everybody and avoiding bag mask ventilation. I'm personally using the Glidescope or some other form of video laryngoscopy on everybody just minimize mouth opening and get the tube in quickly, and during emergence from general anesthesia and extubation, I'm putting my N95 and goggles back on and performing deep extubations on all who don't have any contraindications (A technique where we get the patient breathing spontaneously off of the ventilator while still anesthetized with our volatile agent/gas that prevent patients from bucking and coughing everywhere).

Any MAC bronchs?

[ghillbert, MSN, NP]

Check ELSO> recommend to use VL for intubation instead of DL, avoid bipap, minimize aerosol procedures.

[ProgressiveThinking, MSN, CRNA]

18 hours ago, murseman24 said:

Any MAC bronchs?

N95 and goggles on during the entire case if asymptomatic and low risk. If symptomatic and/or high risk then our protocol is to use a papr and gown up.

[murseman24, MSN, CRNA]

On 3/21/2020 at 11:06 AM, ProgressiveThinking said:

N95 and goggles on during the entire case if asymptomatic and low risk. If symptomatic and/or high risk then our protocol is to use a papr and gown up.

Wouldn't a tube or LMA be better?

[ProgressiveThinking, MSN, CRNA]

12 minutes ago, murseman24 said:

wouldn't a tube or LMA be better?

A tube yes (but even then you can still be exposed), an LMA I'm unsure of. I'm intubating everybody and trying to avoid MAC cases in general unless it's a quick and short case and the patient is low risk.

[subee, MSN, CRNA]

I just read this morning of the technique of wrapping the LMA tube with clear adhesive dressing that covers the mouth and and wraps itself around the tube. Doing intubations outside of the OR is a riskier proposition than under the controlled circumstances of the OR. Having to use Sux allows tube to go in faster but in the rush of attempting to get tube in quickly, the patient might not be totally relaxed and cough in your face. So yes, it can be a messy procedure. I have been thrown up on because staff was not applying enough cricoid pressure.