Care of Mechanically ventilated patients in covid19 persepctives

2. Care of patients on
Mechanical Ventilator-
Covid 19 perspectives
Prepared By
Vijayakrishnan R Msc.RN(Nursing officer –B)
Preethamol Msc.RN(Nursing officer –B)
Ampili.K Msc.RN(Nursing officer –B)
Jesna Nazeem Msc.RN(Nursing officer –B)

3. Introduction
 Corona virus comprises of a large family of viruses that are common in
human beings as well animals (camels, cattle, cats, and bats). There are
seven different strains of corona virus.
 229E (alpha coronavirus)
 NL63 (alpha coronavirus)
 OC43 (beta coronavirus)
 HKU1 (beta coronavirus)
 MERS-CoV (the beta coronavirus that causes Middle East Respiratory
Syndrome, or MERS)
 SARS-CoV (the beta coronavirus that causes severe acute respiratory
syndrome, or SARS)
 SARS-CoV-2 (the novel coronavirus that causes
coronavirus disease 2019, or COVID-19)

4. GOALS
 YOUR PERSONAL PROTECTION IS THE PRIORITY.
 CAREFUL ATTENTION IS REQUIRED TO AVOID SELF-
CONTAMINATION.
 Patient and Health care provider safety by maximizing First
Attempt to Success and limiting contamination and
transmission of the virus by adequate infection prevention and
control practices.

5. PRINCIPLES
Corona virus is highly virulent with a high nosocomial infection rate
Transmission occurs via airborne route /droplet during aerosol generating
procedures like
Nebulization,
Non invasive ventilation(NIV),
 Airway suctioning,
Bag mask Ventilation(BMV),
Highflow nasal oxygenation(HFNO),
Tracheal intubation,
CPR and bronchoscopy

6. PRINCIPLES
 The effectiveness of PPEs to control airborne transmission is
highly dependent on proper fit and use.
 The optimal way to prevent airborne transmission is to use a
combination of interventions, not just PPE alone. This can
provide an additional degree of protection, even if one
intervention fails or is not available.

7. PRINCIPLES
 Engineering controls: Negative pressure airborne
infection isolation rooms with > 12 air changes per minute
are recommended.
 But where the facility is not available, aerosol generating
procedures should be limited to isolation areas / closed
rooms.

8. PRINCIPLES
 Special intubation teams consisting of one intubator, one
assistant and one to administer drugs / monitor patient
who are trained using simulation exercises are highly
desirable for emergency intubation of COVID -19 patients.
 One nurse may wait outside the room in the clean area as a
runner in case additional equipments may be required.
 Prepare a COVID-19 tracheal intubation trolley that can be
used in ICU or elsewhere.

9. PRINCIPLES
 Use a Checklist to make sure that all the necessary
equipment's are available and functional before
entering the room
 Wear full PPE at all times. - Double gloving should be
considered.
 A face shield should be used as an additional
precaution.
 It also helps to reduce the contamination of the protective
eyewear as well as the N95 respirator in situations where
the acute shortage demands an extended use or limited
reuse of these equipments.

10. PRINCIPLES
 Roles and responsibilities have to be clearly defined by
the intubator / team leader and everyone should know the
plan before entering the room.
 The best skilled airway manager present should manage
the airway to maximize the first pass success.
 Multiple attempts increase the risk to sick patients and
staff.

11. Rapid Sequence Intubation
 Rapid sequence intubation is the preferred method.
 Monitor the patient’s vitals before, during and after the procedure.
 Preparation: - Should be done outside the isolation room.
 - Donning of full PPE - Get to know the team members and delegate
the roles and responsibilities.
 Discuss the plan & condition of the patient. - Preparation of
intubation trolley and preloading of drugs.
 Once you enter the room touch as little as possible to avoid
fomites.
 Ensure two functional intravenous accesses.

12. AIRWAY MANAGEMENT: “7 Ps of RSI”
1. Preparation:
2. Preoxygenation:
3. Pretreatment:
4. Paralysis with induction:
5. Protection:
6. Placement:
7. Post‐intubation management:

14. Pre-oxygenation:
 Ongoing controversy exists regarding the optimal method of
pre-oxygenation with regard to Reducing Aerosol
Generation and the available equipments.
 Current options include: - Use of a Non Re-Breather Mask
(NRBM) with a flow rate of 15L/min or higher if the patient is
significantly hypoxemic
 Requires a NRBM to maintain an oxygen saturation > 94%
and is at high risk of rapid desaturation.

15. NRBM may be placed over a triple
layer face mask on the patient

16.  Use a 2-person, 2 –handed bag mask
ventilation with a viral filter between the
mask and the bag and a VE –grip to
improve seal

17.  A non vented NIV mask may be used to achieve
a better seal

18.  A low flow (< 6L/min) is recommended but a higher
flow should be used if this does not meet the patients
flow demand (ie the reservoir bag collapses during
inspiration).
 A low pressure bagging technique may be used if
needed to provide ventilator support for poor
respiratory effort.
 Turn off the oxygen flow before the mask is removed
from the face of the patient for laryngoscopy.

19.  Avoid aerosol generating procedures which includes
high flow nasal oxygen.
 If the patient is agitated due to hypoxia,
pre-oxygenation may be done after giving 0.5 to
1mg/kg of ketamine or 0.01 to 0.03 mg/kg of
midazolam depending on the hemodynamic status of
the patient.
Patient may be positioned in a ramped up
position to facilitate pre-oxygenation as well
as intubation.

20. • Adequate conditions for endotracheal intubation require
appropriate positioning of head and neck. ...
• In obese patients, it is recommended to put the patient in
the ramped position (back-up position with the tragus of the ear is at
the level of the suprasternal notch) in addition to the sniffing head-
and-neck position.

21. RAMPED UP POSITION

22. Induction with paralysis
 Induction of unconsciousness and Complete Paralysis
before laryngoscopy is highly recommended to prevent
coughing by the patient and inadvertent exposure of
the health care provider.
 This also facilitates First Pass Success of Tracheal
Intubation.

23. Induction with paralysis
Drug Cart for intubation
 Propofol: 2 mg/kg IV or
 Ketamine: 2 mg/Kg IV
 Rocuronium: 1mg/Kg IV or
 Scoline: 1.5-2 mg/Kg IV for RSI
 Glycopyrrolate:0.004 mg/Kg IV
 Phenylephrine: 1-2 mcg/Kg IV boluses
 Morphine: 0.1-0.2 mg/Kg Iv boluses (for maintenance)
 Fentanyl: 1-2 microg/ Kg IV boluses (for intubation)
 Dexmeditomedine 0.3-0.5 mcg/Kg/Hr
 Noradrenaline / Adrenaline: 0.02 mcg/Kg/min

24. Induction with paralysis
Wait for the paralytic agents to take effect
(45sec to 1minute) before attending
laryngoscopy.

26. Laryngoscopy with placement of tube
 A video laryngoscope assisted intubation is preferable to
conventional laryngoscopy to reduce the risk of exposure.
 Intubate with a 6.5 to 7.5mm ID (females) and 7 to 8mm ID
(males) tracheal tube.
 Preferably larger tubes should be used to get a proper seal
and avoid the risk of Aerosolization.
 Tubes with subglottic suction port are preferable.
 Stylet may be used to guide the tracheal tube.

27. Laryngoscopy with placement of tube
 Cover the adapter of the tube using a gauze pad to
prevent splashing of secretions while removing the
stylet.
 Do not check the position of the tube without inflating
the pilot balloon with 10ml of air and attaching an
bacterial/ viral filter to the ET tube adapter.

28. Laryngoscopy with placement of tube
 If a stand- alone mechanical ventilator / transport
ventilator is immediately available connect the ET tube
with the Bacterial/Viral filter attached to it to the
ventilator and avoid using a manual resuscitator
(ambubag).
 A closed suction should be pre-connected to the ventilator
circuit if available
 Bacterial /Viral filter to be connected between the expiratory
limb and expiratory cassette

29. Laryngoscopy with placement of tube
 Resheath the laryngoscope blade immediately post intubation with
the outer glove worn by the operator
 Laryngoscope blade-dip in 1% sodium hypochlorite solution
 Use low gas flows and closed circuits
 Avoid ventilator disconnections.
 If the ventilator has to be disconnected it may be done distal to the
Bacterial /Viral filter attached to the ET tube or after Clamping the
ET tube.

31. Post intubation sedation and
analgesia:
 Provided with Midazolam infusion at 0.05 to 0.1mg/kg/hr
 Fentanyl infusion at 0.5 to 1.5mcg/kg/hr.
 Dexmedetomidine may also be used (0.2 to 0.7mcg/kg/hr).
 Loading dose (1mcg/kg) may not be required for adults
converted from other sedative therapy.
 Neuromuscular paralysis may be maintained with
Vecuronium at 0.05 to 0.1mg/kg/hr infusion or as hourly
boluses

32.  If you face a Can’t Intubate Can’t Oxygenate (CICO)
situation, proceed with emergency Front Of Neck
Access (eFONA) procedure like surgical
Cricothyroidotomy.
 One of the team members or a person with full PPE
who waits outside the room should have the
expertise for eFONA if the situation arises.

33. Communicate clearly: simple instructions,
closed loop communication (repeat
instructions back), Adequate Volume
Shouting.
 Place a nasogastric tube after tracheal
intubation is completed and ventilation
established safely.

34.  If COVID-19 status not already confirmed take a deep
tracheal aspirate for virology using closed suction.
 Closed suction (if available) is preferred for clearing the
tracheal tube.
 Discard disposable equipment safely after use.
 Decontaminate reusable equipment fully and according to
manufacturer’s instructions.
 After leaving the room ensure doffing of PPE is Meticulous
and Coached by a Teammate.
 Clean room 60 minutes after tracheal intubation (or last
aerosol generating procedure).

35.  Positioning-head end of the bed elevated at 30 degree
 In adult patients with ARDS, prone ventilation for 12-16
hours per day is recommended

36. Post Intubation with Closed
Suction Connected

37. CLOSED SUCTION SYSTEM

38. SUCTIONING
 Assess the need for suctioning
 Explain the procedure, sedate as needed
 Adequate sedation & paralysis prior to suction to
minimise aerosol generation.
 Place the patient in supine position with head slightly
extended.
 Hyperoxygenate with 100% FiO2 for 30-60 seconds
 Sedate with Morphine or Fentanyl bolus 2-3 min
before suction.

39.  Size of catheter (1/2 – 2/3 the diameter of ET), Fr. No. 12, 14,
16 - adults.
 Suction pressure - 80-120
 Avoid bag and mask ventilation. Can be used if required by
connecting Bacterial /Viral Filter
 Prefer closed suction technique to decrease Viral Aerosol
production
 If it is not available, suction should be done by minimum
members of the team
 Do oral suction prior to ET
 Use separate catheters for oral, nasal and tracheal
 Clamp the ET tube when disconnection is required. Do not
Keep ET tube open to air

40. SUCTIONING
 Insert till resistance withdraw 2-3 cm and apply
suction
 Do not apply suction while inserting the catheter.
 During removal, rotate the catheter for effective
removal of secretions
 Check ET tube level after suctioning

41. PREVENTION OF ASPIRATION
 Use cuffed tube
 cuff pressure of at least 20-25 cm H2O(no audible air leak)
 Aspiration of subglottic secretions
 Oral and nasal suction
 Feeding-semi-recumbent position ( head of the bed to 30-45°).
 Gastric decompression –Ryles tube, medications

42. EXTUBATION
 Tracheal extubation should be done on table ,as far as possible.
 Prophylactic anti emetic
 Adequate Pain management: Morphine/ Fentanyl boluses
 Careful & gentle oral suctioning may be performed
 Patient should be ideally ready for extubation on to face mask
 Keep the adequate size facemask ready on the forehead
 A transparent plastic sheet may be placed over the patient’s face during
extubation to prevent splash
 A simple oxygen mask should be placed on patient, immediately post
extubation to minimise aerosolization from coughing
 An N95 mask may be kept over patients face after extubation.

43. EXTUBATION
 All efforts to prevent coughing
Aerosol generation should be prevented:
Extubation under transparent sheet O2 by Nasal cannula / face mask
 NIV or High flow O2 can cause aerosol generation
 Proper doffing and Hand hygiene after each step

44. Do Not Attempt
 Bag-Mask ventilation,
 NIV
 Open suctioning
 FOB,
 Supraglottic airway devices
 Circuit disconnection
 Nebulization

45. Checklist for Intubation trolley
1. Video laryngoscope, 2 Tested Laryngoscopes
2. 2 Tested Endo tracheal Tubes
3. Bag &Mask Ventilation unit with a Viral Filter +/ – a circuit mount
attached to it or non vented NIV mask of appropriate size.
4. Double limb ventilator circuit with closed suction.
5. Stylet
6. Gum elastic Bougie
7. Yankeur suction catheter and suction tube
8. Tube tie /Plaster
9. Clamp

46. Checklist for Intubation trolley
10. Scissors
11. 10 cc Syringe, 5 cc Syringe
12. Emergency front of neck access kit (Scalpel with no 10
blade, 6mm ID ET Tube/ Tracheostomy tube.)
13. 4X4Gauze Piece -2
14. Lubricant Gel
15. Gastric tube ,Tape
16. Drugs

51. Thank You For Your
Attendance!!!!!
Remember, PPE is only
effective in protecting you,
When You Use It