MICHAEL MARINO: Hello, and welcome to this COVID 19 essentials for the health care worker brought to us by the Mayo Clinic School of Continuous Professional Development, a rapid response series. I am Michael Marino. I'm assistant professor and senior associate consultant of otolaryngology. And in this presentation we will be discussing special circumstances for airway and EMT procedures.

I've no financial disclosures or conflicts of interest related to this presentation. The objectives of this presentation will be to understand that airway management is an inherently high risk procedure for aerosol based transmission. To define aerosol generating procedures and potential events. To develop a systematic approach for the intubation of critically ill patients. As well as a systematic approach to AGP management.

Both laryngoscopy and tracheal intubation can generate aerosols making these high risk procedures. Endoscopy and the use of powered instrumentation in the aerodigestive tract or instrumentation within the nasal cavity may also aerosolize secretions. Secondly, the patient may become agitated or combative, or cough during intubation creating aerosols. During these procedures, the health care provider is also in close proximity to the airway creating another potentially high risk situation.

There are several aerosol generating events. This includes coughing and sneezing, the use of non-invasive ventilation, as well as high flow nasal oxygen. The delivery of nebulizer atomized medications, which includes nasal sprays, maybe aerosol generating events as well. Cardiopulmonary resuscitation, when the patient is not intubated, can be a potential aerosol generating event. Tracheal suction without a closed system, as well as tracheal and esophageal exhalation may be aerosol generating events.

Finally, powered instrumentation within the nose or nasal pharynx can create aerosolized particles. There are also several aerosol generating procedures. Specifically, this includes tracheostomy, esophagectomy, pulmonary lobectomy, sprays used within the nasal cavity and nasal pharynx, nasal endoscopy as well as flexible laryngoscopy, sinus surgery, and post sinus surgery debridement, transnasal skull base surgery, glossectomy, tonsillectomy, bronchoscopy. Transesophageal echocardiogram may also be an aerosol generating procedure.

More broadly any procedure which involves entry into or through the aerodigestive tract mucosa has the potential to create aerosolized particles. Aerosol generating events should be avoided and prevented as much as possible in airway management. Non-invasive ventilation and high flow oxygen are of unclear benefit in severe respiratory failure. And given that these are potential aerosol generating events, recommendation is to avoid these procedures when possible.

It's also important for the health care provider and staff to maintain safety. That applies to both the patient and the health care staff. Also it is recommended to be accurate, to avoid performing procedures in which the health care provider is not familiar, or which are of unproven benefit.

Finally, swift action is recommended such as to not delay intervention. But there is also importance in not rushing and taking time to properly don appropriate personal protective equipment.

Suggestions for a premade COVID-19 intubation tray include various useful instruments for the health care provider. This includes videolaryngoscope blades if these are available and if the practitioner is familiar in their use. Also a Macintosh direct laryngoscope blade as recommended as well.

Supraglottic airways should be available for emergency situations. Although, these should be avoided to be used if possible since these may produce aerosolized particles. Endotracheal tubes in the appropriate size range should be available to the intubating team. Bougies and stylets should be available for difficult intubation situations as well as appropriate syringes for endotracheal tubes.

Tube ties should be available prior to intubation. Viral filters should be available to be placed within the circuit after intubation is completed. We will discuss this further in the next slides. End tidal capnography should be available to confirm correct placement of endotracheal tubes. Nasogastric tubes should be available to the intubating team as to reduce a second event of nasogastric tube placement, which can be a potentially aerosolizing procedure.

Oropharyngeal, nasopharyngeal airways should be available as well as a cricothyrotomy kit in an emergent situation in which a external front of neck airway is required.

Circuit setup for the intubated COVID-19 patient should include viral filter, this is critical. This should be placed directly on the endotracheal tube as so that to minimize the number of disconnections that is possible prior to the viral filter. End tidal capnography is then connected distal from the patient from the viral filter.

When preparing to perform a intubation, particularly in the COVID-19 patient, preparation should be made for a difficult airway. And if a difficult airway is expected, an experienced anesthesiologist should be available. The entire team should have appropriate personal protective equipment. A negative pressure room should be used if this is available to the intubating team. Also, if an anteroom is available, this should be used to store additional equipment which may be necessary for difficult intubations including bronchoscopes, carts. Runners may also be used within the anteroom and external to the intubating room to be able to acquire additional equipment as needed.

Pre-oxygenation should be performed using a vice grip or VE maneuver. A one handed CE maneuver should not be used as this is less likely to have a airtight seal. Again, preference should be for the vice grip, two handed seal.

Following the intubation procedure, outer gloves should be removed and additional PPE should be doffed correctly. The N95 mask respirator should be removed once the health practitioner is outside of the intubating room. Airway equipment that is used during the procedure should be placed in the appropriate sealed bag.

For patients who may be going into an aerosol generating procedure, there is a suggested workflow. COVID-19 testing should be performed 24 hours prior to the procedure if this is possible. If a patient is positive for COVID-19, delaying the procedure until the virus clears should be considered strongly. In the event that emergent cases occur and COVID testing cannot be achieved before the procedure, appropriate use of N95 P100 or powered air purifying respirators should be used for these cases. There should be an effort to limit the amount of operating room personnel so that contact with a potentially infected the patient is minimized.

Modified droplet PPE should be used for all the anesthesia and operating room staff during one of these procedures. Again, the respirators should not be removed while inside the operating room. These should be correctly doffed after the health care practitioner leaves the operating room.

Also there are enhanced post-extubation criteria for patients who are either positive for COVID-19 or who have unknown status, or who have had an aerosolized generating procedure.

More broadly, the approach to AGPs should be to delay all elective cases. This is cases of which can safely be delayed for four to eight weeks time. Delaying procedures of this kind as is helpful for protecting the patient and staff. It will also preserve PPE supplies, and finally, reduce the burden of post-operative health care requirements on the health care team.

For urgent AGP procedures, preoperative COVID testing is recommended 24 hours prior to the procedure, and appropriate PPE is required for all of the OR staff, particularly when testing is not possible. Again, all ENT and aerodigestive tract procedures are potentially high risk for aerolization during the procedure.

Other considerations for aerodigestive tract endoscopy and surgeries include that there is potential increased viral load within the nose and nasopharynx and aerosolization civilization it is potentially more likely to spread viral particles. Again, we recommend limiting the number of personnel within the operating room, and to use appropriate precautions in these procedures. The appropriate respirators should also be removed when these procedures are performed.

Finally, the operating room should be closed for approximately 20 minutes to 3 hours depending on operating room airflow as part of an enhanced extubation protocol.

There have also been tracheotomy recommendations. These include recognizing that tracheotomy is a high risk aerosolization procedure. That this procedure should be avoided in COVID-19 positive or suspected patients, and particularly those with respiratory instability. A tracheotomy may be considered for patients who are two to three weeks post-intubation and preferably who have had a negative COVID-19 testing at that point.

It is important to maintain cuff inflation and limit cuff leaks if a tracheotomy has been performed. Also, the use of a heat and moisture exchanger or an HME device with a viral filter should be used if the patient is disconnected from mechanical ventilation. This will prevent the aerosolization of viral particles. Again, tracheotomy tube change should be delayed should be delayed until the patient is COVID negative by testing.

Reviewing PPE considerations for practitioners during aerosol generating procedures. Respirator options include the N95 mask as well as P100 masks if these are available to the team. These also can be potentially reusable. Controlled air purifying devices as well as powered air purifying devices are potential options as well. A limitation to using a powered air purifying device is that the external portion of this may not be sterile and cannot necessarily be used with a sterile procedure.

Eye protection is also a critical part of appropriate PPE for these procedures. This includes face shields and protective eyewear, impervious gowns are recommended as well as using double gloves.

In this slide is a schematic diagram of alerts for aerosol generating procedures that may be in progress. This may help alert the health care team that these procedures are under way when these are displayed outside the appropriate procedure and operating rooms. This will alert the team to use appropriate personal protective equipment when entering the room. As we discussed before, this includes appropriate gowns, respirators, eye protection, and gloves.

The information sheets can also include information about proper donning of personal protective equipment. We'll also perform a demonstration of this in a later presentation.

It's also important for the health care practitioner to use a properly fit tested respirator mask, and to perform a seal check after donning this equipment. Again, proper face shields are also important to protect the eyes from aerosolized particles. And a spotter can also be used when donning equipment to make sure the personal protective equipment is properly donned before entering the procedure or operating room.

In these guides, doffing procedures are also shown. This will also be demonstrated in a later presentation. However, briefly this involves first removing gloves and then eye protection. Hand hygiene should be performed between each step. And next the gown and then respirator are removed after leaving the procedure room.

Moving on, patients who are having interventional procedures can be classified into three classifications in which case different personal protective equipment recommendations are made. Class one patients include patients who are both COVID negative and are having a non-aerosol generating procedure. For these, enhanced intubation procedures are recommended. However, OR staff can use routine personal protective equipment.

Extubation is also performed with droplet precautions and the OR staff can wait outside of the operating room for these classification of patients. Class two patients includes patients in whom COVID-19 status is unknown as well as all aerosol generating procedures regardless of COVID status. In this situation, intubation is again performed with enhanced safety for the intubating team. The OR staff is recommended to use modified droplet precautions, including the use of respirators. Extubation is performed in the operating room. And additional enhanced procedures are performed in this scenario, particularly extended turnover time prior to the next case.

The class three patients includes positive patients who have known COVID-19. In this scenario, negative pressure rooms are recommended for both intubation and extubation of patients.

In summary, airway and aerodigestive procedures are high risk for aerosol generation, and this should be of importance to the health care provider. Having a plan, preparing properly for these procedures, using appropriate protective equipment, and performing procedures in a accurate, safe, and swift fashion can help to ensure patient safety as well as the health care team safety.

Thank you for paying attention in this brief presentation on special considerations for airway and ENT procedures in the COVID-19 setting.