COVID-19 interventions

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Interventions

Airway management

Non-invasive ventilation (NIV) and High Flow Nasal Oxygen (HFNO)

NIV and HFNO must be avoided as they present a high risk of aerosol transmissibility

Mechanical Ventilation

• Mechanical ventilation can be used in patients who have labored breathing and are unable to maintain adequate gaseous excange leading to hypoxemia and/or hypercapnia.
• Common clinical indications of mechanical ventilation include moderate to severe dyspnea, respiratory rate (RR) > 24-30/min, signs of increased breathing, accessory muscle use for breathing and abdominal paradox. It may also be used in patients who have inadequate arterial partial pressure of oxygen or critically low PaO2 (PaO2 < 70 mm Hg), hypercapnia PaCO2 > 45 mm Hg and PaO2/FiO2 < 200.
• The following ventilator setting should be used:
  • Tidal volume: 4 to 6 ml/kg predicted body weight, PBW) and lower inspiratory pressures
  • Plateau pressure (Pplat) < 28 to 30 cm H2O
  • PEEP must be as high as possible to maintain the driving pressure (Pplat-PEEP) as low as possible (< 14 cmH2O)
  • Use of paralytics is not recommended unless PaO2/FiO2 < 150 mmHg
  • Prone ventilation for > 12 hours per day

Special Considerations

In patients suffering from COVID-19, airways management can be high-risk due to aerosol-based transmission for the following reasons:

• Combative or agitated patient secondary to hypoxia
• Personal protective equipment may need to be removed
• Clinicians in close proximity to the patient's airway may be at risk
• Larygoscopy and intubation may become high risk secondary to aerosol generation

Aerosol Generation Risk Factors and Protective Measures

Route of Aerosol Generation	Protective Measures
Coughing	Utilize full personal protective equipment (PPE) prior to entering intubation room Minimize period between removal of patient's PPE and application of face mask with viral filter Ensure sealing of face mask Adequate dosage and time for paralytic drugs
Face Mask Seal Leak	Optimum fitting of face mask Vice (V-E) grip Use manual ventilation ambu bag ETO2 monitoring
Inadequate Seal With Positive Pressure Ventilation
High Flow Nasal Oxygen