COVID-19 Intubation Recommendations

Recommendations for COVID-19 intubation: An Infographic

In All Posts, Infographics, Medical Concepts by Patrick Boreskie6 Comments

Updated March 13, 2020

Intubation and the steps leading up to it are some of the highest-risk moments for COVID-19 spread to healthcare workers and other patients.​1,2​ In Wuhan, “intubation teams” were established to perform multiple intubations per hour while maintaining strict protocols to limit viral exposure. Who is going to be part of your intubation team? What gear and approach will you use? How will this differ from the average intubation? This infographic was created as a visual reminder of the emerging best practices for intubating a COVID-19 suspect, based on current evidence from China and prior understanding of SARS. Recommendations may evolve with further research.

Droplet vs Airborne

Many of the recommendations in this infographic are based on the fact that droplet precautions will not be enough to protect against COVID-19 spread during intubation. As a reminder, droplet spread is caused by viral particles within small drops of bodily fluids. Considering their larger size and mass, they fall with gravity within a couple meters. Airborne or aerosol spread on the other hand, is through particles small enough to be borne on air currents and can spread much further or “hang” in enclosed rooms. This explains the difference in infectious precautions between pertussis and tuberculosis, for example. Unfortunately, many illnesses typical for droplet spread can also become aerosolized which is of utmost importance when considering intubation of a COVID-19 suspect. Enclosed spaces will increase the predominance of airborne particles, as will the iatrogenic assistance of nebulizers, high-flow oxygen, and positive pressure ventilation.​3,4​ There are massive healthcare cost implications when a disease is considered airborne beyond spread by droplet, due to the increased isolation requirements and PPE.​5​ Though viral viability and culture were not tested, PCR testing of COVID-19 patient rooms (even with only mild respiratory symptoms) showed gross contamination of surfaces like shoes, handles, and toilet seats prior to cleaning, while also showing contamination in fan vents.​6​

Minimizing Aerosolization

Regardless of what your local isolation protocol is for COVID-19 suspects receiving care in the hospital (The CDC is being very cautious by basically recommending aerosol precautions at all times), intubation should be considered a time when production of airborne particles is a certainty. As such, limiting the components of intubation that can send aerosolized virus into the room should be a priority. High-flow oxygen, including BiPAP, high-flow nasal cannula, the high L/min O2 required for nebulizing, aggressive suctioning, bagging (yes, with a BVM!) all have been linked to aerosolization and infection spread in SARS.​7​ The COVID intubation protocol for one Hong Kong hospital even advocates for supraglottic device use if bagging for preoxygenation is necessary.​1​ The intubation attempt should be as quick as possible with a fully paralyzed patient with the minimum safe number of people in the room – now is not the time for a medical student to try direct laryngoscopy before you take over!​2​ Video laryngoscopy might limit proximity to the airway compared to direct, so it is likely your best bet. Also, it makes sense to avoid the periods of time when the ETT is in place, but not connected to a closed circuit (i.e. switching off the BVM post-intubation to attach the ventilator). Aerosol and droplet spread could be prevented by either clamping the tube during the swap, or leaving a viral filter in place on the ETT.

Personal Protective Equipment

Despite our best efforts, the production of airborne particles during intubation is likely. Protect yourself by wearing an N95 mask and face shield. A surgical mask will not prevent airborne transmission. Wear a fluid-resistant gown and single-layer gloves (the CDC says routine hospital gloves are fine). Furthermore, intubations should be performed in a room deemed suitable for airborne isolation (reverse-isolation negative pressure room with antechamber, or advanced filtration such as a HEPA scrubber). PPE should be left in the room and garments under gowns should not leave the department.

Plan Early and Realistically

Whether due to resource constraints or a precipitously crashing patient, adhering to these recommendations may not always be possible. Regardless of your local context, take another glance at this infographic when a patient with suspected COVID-19 is worsening. Mentally rehearse for an intubation that is best for your situation… and stay safe!

For the latest information on the COVID-19 outbreak, read our COVID-19: Fast Facts post.

For more FOAMed on airway control in COVID-19, check out EMCrit and Life In The Fast Lane.

Download Infographic
  1. 1.
    Cheung JC-H, Ho LT, Cheng JV, Cham EYK, Lam KN. Staff safety during emergency airway management for COVID-19 in Hong Kong. The Lancet Respiratory Medicine. February 2020. doi:10.1016/s2213-2600(20)30084-9
  2. 2.
    Zuo M, Huang Y, Ma W, et al. Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019. cmsj. 2020:0. doi:10.24920/003724
  3. 3.
    Somogyi R, Vesely AE, Azami T, et al. Dispersal of Respiratory Droplets With Open vs Closed Oxygen Delivery Masks. Chest. March 2004:1155-1157. doi:10.1378/chest.125.3.1155
  4. 4.
    Smieszek T, Lazzari G, Salathé M. Assessing the Dynamics and Control of Droplet- and Aerosol-Transmitted Influenza Using an Indoor Positioning System. Sci Rep. February 2019. doi:10.1038/s41598-019-38825-y
  5. 5.
    Tellier R, Li Y, Cowling BJ, Tang JW. Recognition of aerosol transmission of infectious agents: a commentary. BMC Infect Dis. January 2019. doi:10.1186/s12879-019-3707-y
  6. 6.
    Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. JAMA. March 2020. doi:10.1001/jama.2020.3227
  7. 7.
    Yu IT, Xie ZH, Tsoi KK, et al. Why Did Outbreaks of Severe Acute Respiratory Syndrome Occur in Some Hospital Wards but Not in Others? Clinical Infectious Diseases. April 2007:1017-1025. doi:10.1086/512819

Patrick Boreskie

Dr. Patrick Boreskie is a chief Emergency Medicine resident at the University of Manitoba in Winnipeg. He is a CanadiEM Digital Scholars Fellow and International Conference on Residency Education Chief Resident. He has a particular interest in knowledge translation, gerontology, and ultrasound.

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