Invasive Ventilation

Practical Guidelines for COVID-19 Patients

Dr. Muhammad Mohsin Ali
Medical Officer
Anesthesia and ICU
Indications of Intubation
• Signs of respiratory distress (eg, accessory muscle use; paradoxical
abdominal breathing)
• Worsening mental status, evolving hypercapnia and increased work of
breathing
• Rapid progression of disease
• SpO2 sat <90% despite maximal supplemental oxygen
• Arterial pH <7.3 with PaCO2 >50
• Patient requiring >40-50 L/minute HFNC and FiO2 >0.6—lack of improvement
• Hemodynamic instability; multiorgan failure
Timing of Intubation
• Timing is particularly challenging—Delaying intubation until the
patient acutely decompensates is potentially harmful to the patient
and healthcare workers and is not advised
• For patients who meet the indications described previously—have a
low threshold to intubate
• Usually, early intubation is suggested—still unclear what exactly
constitutes ‘early’
Intubation Precautions
• Intubation is the highest risk procedure for droplet dispersion in
patients with COVID-19
• Develop: intubation kits and checklists; Collect Materials in advance:
• Airway boxes (nasopharyngeal airways, oral airway, syringes, needles, LMA’s,
blue “bougie” stylet, extra ETT’s 6.0-8.0)
• Medication boxes(paralytics, phenylephrine, ephedrine, epinephrine,
lidocaine, labetalol, esmolol, propofol/etomidate, midazolam)
• Dedicated video laryngoscope.
• Rapid Sequence Induction (RSI) should be performed by the most
experienced airway provider using a video laryngoscope
Precautions (cont.)
• Donning with appropriate PPE (N95/PAPR, eye protection/face shield,
double gloves, gown, caps, neck-cover and shoe-covers)
• Do all intubations/extubations in airborne infection isolation room
• Limit providers in room to 3: 1 airway team member(s), respiratory
therapist, and registered nurse
Procedure
• Pre-oxygenate until neuromuscular blockade sets in
• Option 1: 3-5 minutes of tidal breathing 1.0 FiO2 on non-rebreather at 15L/min flow
• Option 2: facemask attached to AMBUbag with HEPA filter (2 hand technique to maintain seal)
• Option 3: if patient already on BiPAP then maintain BiPAP with tight seal until ready to
intubate(turn “OFF” BiPAP flow prior to removing mask)
• Intubate using RSI with video laryngoscopy
• After intubation: inflate cuff, connect to vent with HEPA filter, confirm
(quantitative in-line EtCO2 (gold standard > 3 breaths), bilateral chest rise,
“fogging” of ETT, cuff palpation and possibly increasing SpO2), and secure
ETT
• Clean layngoscope
Ventilator Management
Provide low tidal volume ventilation:
• Volume limited Assist Control with TV target 6 mL/kg predicted body
weight [PBW] (range 4 to 8 mL/kg PBW)
• RR 25 to 30 to start; goal 10 to 15 breaths/minute
• PEEP/FiO2: PEEP 10 to 15 cm H2O to start
• Titrate oxygen to target PaO2 55 to 80/SpO2 90 to 96 for most
patients
• Plateau pressure <30 cm H2O
• Goal pH >7.15
What to do after attaching Ventilator?
• Obtain STAT portable CXR to confirm endotracheal tube location
• Prioritize CXR and vent settings over procedures (such as central venous catheter placement) if possible.
• Obtain an ABG (preferred) or a VBG within 30 minutes
• Calculate P/F ratio from initial post-intubation ABG. Adjust oxygenation based on ARDSnet guidelines (link at
end)
• Goal pH 7.25 to 7.45:
• If pH > 7.45, decrease respiratory rate
• If pH 7.15-7.30, then increase respiratory rate until pH > 7.30, or PaCO2 < 25 (maximum RR= 35
breaths/minute)
• If pH < 7.15, then increase respiratory rate to 35 breaths/minute while monitoring for full
exhalation between breaths
• If pH still < 7.15, then perform the following:
• Tidal volume may be increased by 1 mL/kg until pH > 7.15 (until plateau pressure reaches 30
cm H2O or tidal volume reaches 8 cc/kg)
• Deep sedation advancing to RASS -5 if needed
• If still no improvement, initiate prone ventilation (may improve V/Q matching and better
ventilation)
Failure of LTTV
• Defined by PaO2/FiO2 [P/F] ratio <150 mmHg × 12 hours or worsening
oxygenation after intubation
• Prone ventilation (12-16 hours prone per day)—effects seen over 4-8
hours
• If failure of prone ventilation:
• Recruitment maneuvers and high PEEP strategies
• Trial of inhaled pulmonary vasodilators such as NO/epoprostenol
• Neuromuscular blockade for patients with refractory hypoxemia (eg, P/F <100
mmHg) or ventilator dyssynchrony
• ECMO as a last resort: not universally available
Management of ventilated patients
• Daily CXR. Indications:
• Clinical change
• Concern for displaced ET tube:
• Sudden increase in peak inspiratory pressure or resistance
• Decreased, unilateral breath sounds (usually on the right)
• RN or RT concern for change in depth of ET tube at teeth
• ICU best practice bundle
• Ventilator consults