*7.2.4 Pre-oxygenation*

Preoxygenation is crucial part before intubating covid 19 patients as these patients are ill and prone to very rapid desaturation due to the nature of the disease. When it is possible 3–5 minutes of preoxygenation is recommended using non rebreathing mask with 10–15 liter/O2 which provide 100% Fio2, if NRM is not enough modified non invasive ventilation might needed with close circuit and HEPA filter. If bagging the patient is inventible for preoxygenation this should be done with two hand technique with HEPA filter however avoiding bagging the patient is always recommended when it is possible [38].

Ideally pre-oxygenation could avoid necessity of bag mask ventilation but there is no guarantee especially in critical COVID 19 patients.

**Figure 2.**

*Ventilation circuits setup (image courtesy Dr. Nabil Shallik).*

Keeping the patient in 45 degree (reverse Trendelenburg positioning)may help in increasing apnea time improving the preoxygenation .

#### *7.2.5 Fibroscopic intubation*

Flexible bronchoscope can be used in anticipated difficult airway however, it is not advised to be used routinely. But if you in real need in difficult case, better to shift to single use fibro scope [37].

#### **7.3 During intubation**

Endotracheal Tube (ETT) confirmation site should be confirmed by ETCO2 because full PPE will make auscultation much difficult and using stethoscope impractical. Clinically observing chest rising may help in precluding unilateral intubation. Also seeing the ETT passing through vocal cord and recording using video laryngoscopic screen is the best way of confirmation of endotracheal intubation.

As most of COVID 19 patients who need mechanical ventilation will have ARDS so, lung protective mechanical ventilation strategies should be used (target tidal volume less than 6 mLkg 1 predicted body weight, plateau pressure ≤ 30 cm H20, target SaO2 88–95% and pH ≥ 7.25 [38].

The most experience intubator should perform the intubation in order to achieve high first pass success [39] and reduce the contamination and the intubator should use a technique which he is familiar and comfortable with.

Many of novel devices have been introduced trying to achieve high level of protection during the intubation procedure itself, like novel intubation plastic box and plastic cover. Yet there is no definite evidence that such these devices could really protect the intubator from the aerosols [40], few articles suggested that and current studies are ongoing to prove it.

• In cardiovascular instability induction agents should be chosen carefully for the

• Regardless of the choice of induction agents, ensure that the patient is deep enough before starting intubation to prevent coughing and straining during

• As RSII is recommended, the rapid acting muscle relaxant should be used in a good dose to ensure complete relaxation that the patient will not cough for

• As many patients could have severe hypotension, loaded vasopressors should be immediately available for bolus or infusion. Phenylephrine, Ephedrine can

• Some experts recommended Continuous Positive Airway Pressure (CPAP) with good sealing as this might help to delay desaturation with apneic oxygenation, using proper size oral airway after induction will help in maintaining the airway patency. If CPAP is not enough to prevent

and minimal oxygen flow and minimal airway pressure (**Figure 4**).

desaturation, then bag-mask ventilation should start with two hand technique

• While video-laryngoscope is the best option to start yet using adjunctive is pretty helpful for C-MAC Macintosh blade and C-MAC D-blade (Karle Storz, Germany); it is a good idea to use Gum Elastic Bougie (GEB) in case needed. Also, stylet can be used to ease intubation with GlideScope (Verathon, Burnby, BC, Canada). If video

best hemodynamic stability i.e. (Ketamine, Etomidate).

*Airway Management in COVID-19 as Aerosol Generating Procedure*

*DOI: http://dx.doi.org/10.5772/intechopen.96889*

*Plastic intubation box (image courtesy Dr. Nabil Shallik).*

intubation and this will lead to aerosolization of organisms.

example (Succinylcholine 1.5 mg/kg, Rocuronium1.2 mg/kg).

be used as a first line.

**Figure 3.**

**11**

One of the common novel devices recently introduced is intubation novel box. First time had been described by Dr. Lai Hsien-yung [41], The device composed of a transparent plastic cube covering a patient's head and shoulders, with access holes for the intubating procedure and additional hole for an assistance. These device have been discussed in medical literature [42]but more commonly on social media and medical education websites, often being praised for their ingenuity (**Figure 3**).

Brown et al., has created "Barrier System for Airway Management of COVID-19 Patients" it is simply a plastic drape attached to a plastic bag as a protective measure during end tracheal intubation and extubation [43].

#### **7.4 Some tips and tricks during intubation**


*Airway Management in COVID-19 as Aerosol Generating Procedure DOI: http://dx.doi.org/10.5772/intechopen.96889*

Keeping the patient in 45 degree (reverse Trendelenburg positioning)may help

Flexible bronchoscope can be used in anticipated difficult airway however, it is not advised to be used routinely. But if you in real need in difficult case, better to

Endotracheal Tube (ETT) confirmation site should be confirmed by ETCO2 because full PPE will make auscultation much difficult and using stethoscope impractical. Clinically observing chest rising may help in precluding unilateral intubation. Also seeing the ETT passing through vocal cord and recording using video laryngoscopic screen is the best way of confirmation of endotracheal

As most of COVID 19 patients who need mechanical ventilation will have ARDS so, lung protective mechanical ventilation strategies should be used (target tidal volume less than 6 mLkg 1 predicted body weight, plateau pressure ≤ 30 cm

The most experience intubator should perform the intubation in order to achieve high first pass success [39] and reduce the contamination and the intubator should

Many of novel devices have been introduced trying to achieve high level of protection during the intubation procedure itself, like novel intubation plastic box and plastic cover. Yet there is no definite evidence that such these devices could really protect the intubator from the aerosols [40], few articles suggested that and

One of the common novel devices recently introduced is intubation novel box. First time had been described by Dr. Lai Hsien-yung [41], The device composed of a transparent plastic cube covering a patient's head and shoulders, with access holes for the intubating procedure and additional hole for an assistance. These device have been discussed in medical literature [42]but more commonly on social media and medical education websites, often being praised for their ingenuity (**Figure 3**). Brown et al., has created "Barrier System for Airway Management of COVID-19 Patients" it is simply a plastic drape attached to a plastic bag as a protective measure

• Modified Rapid Sequence Induction and Intubation (RSII) is advised as it reduces the time to intubation as securing the airway, with or without cricoid

• Bag mask ventilation should be minimized unless there it is indicated

• Optimizing the patient position for intubation is recommended as any other intubation tool as video-laryngoscope will be used straight line head which suppose make the intubation more convenient, in obese patient ramping

in increasing apnea time improving the preoxygenation .

*Special Considerations in Human Airway Management*

*7.2.5 Fibroscopic intubation*

**7.3 During intubation**

intubation.

shift to single use fibro scope [37].

H20, target SaO2 88–95% and pH ≥ 7.25 [38].

current studies are ongoing to prove it.

use a technique which he is familiar and comfortable with.

during end tracheal intubation and extubation [43].

pressure. Drugs of choice are discussed later [44]

3–5 minutes of pre-oxygenation with 100% will help.

**7.4 Some tips and tricks during intubation**

position is recommended.

**10**

**Figure 3.** *Plastic intubation box (image courtesy Dr. Nabil Shallik).*


• **Difficult airway management:**

*DOI: http://dx.doi.org/10.5772/intechopen.96889*

complications.

**Figure 5.**

**13**

Difficulty can happen in many aspects:

1.Facemask ventilation is not adequate,

2.Placement of a supraglottic airway (SGA) is difficult,

*Airway Management in COVID-19 as Aerosol Generating Procedure*

5.COVID 19 intubation trolley should be ready.

3.Laryngoscopy and tracheal intubation: inability to intubate the patient.

4. Same consideration for non- COVID patients will be applied in COVID19 patients, nevertheless the reason of difficulty, the crucial part is to have a pre-prepared plan and being well ready in order to avoid any serious

6.The cause of difficult airway actually is multifactorial including the effect of patient factors, the clinical setting, and the skills of the practitioner.

Declare the status clearly to team members is very important, in case FONA needed the recommended technique is the one to minimize aerosol generating i.e. The scalpel bougie-tube technique as using high flow oxygen could generate

*(a) Tracheal intubation adapted for COVID 19 patient & (b) CICO adapted for COVID 19 patients. Taken*

*with permission from Difficult Airway Society (DAS) 2015 guidelines [45].*

7.There are many local institutional policies and algorithm to manage

anticipated and unanticipated difficult airway (**Figure 5**).

#### **Figure 4.**

*(*√*): Two-handed two-person bag-mask technique with the VE hand position; the second person squeezes the bag. (X): The CE hand position, which should be avoided. (image courtesy Dr. Nabil Shallik).*

laryngoscope is not available for any reason direct laryngoscopy could be other option using Macintosh blade with Gum Elastic Bougie (GEB) help.


*Airway Management in COVID-19 as Aerosol Generating Procedure DOI: http://dx.doi.org/10.5772/intechopen.96889*
