Consensus guidelines for managing the airway in patients with COVID‐19

The predominant COVID‐19 illness is a viral pneumonia. Airway interventions are mainly required for tracheal intubation and establishing controlled ventilation. This consensus statement has been brought together at short notice to advise on airway management for patients with COVID‐19, drawing on published literature and immediately available information from clinicians and experts.

Paediatric “tube” sizes

You decided to intubate a child and wisely remembered that you should also follow with an NG/ OG after intubation to decompress the stomach.  In order to avoid the blank stare when asked “what size”?  Here’s a nice mnemonic about Pediatric “tube” sizes… easy as 1-2-3-4!!!  Please note ETT = endotracheal tube size.

  • 1 x ETT = (age/4) + 4 (formula for uncuffed tubes)
  • 2 x ETT = NG/ OG/ foley size
  • 3 x ETT = depth of ETT insertion
  • 4 x ETT = chest tube size (max, e.g. hemothorax)

So for example, a 4-year-old child would get intubated with a 5-0 ETT inserted to depth of 15 cm (3x ETT), a 10Fr NG/OG/foley (2x ETT), and a 20Fr chest tube (4x ETT).

Also, remember that you can use cuffed tubes in any child except neonates but the formula needs to be adjusted as follows: cuffed endotracheal tube ID (mm) = (age/4) + 3.5

Rapid Sequence Intubation Medications

Induction Agents

Medication Weight-Based Dosing Time to Onset of Action Adverse Effects/

Contraindications

Etomidate 0.3 mg/kg <1 minute May cause clinically insignificant adrenal suppression.
Ketamine 1-2 mg/kg 1-3 minutes May increase blood pressure. May cause hypersalivation.
Propofol 2 mg/kg <1 minute May cause hypotension. Cardiac depressant. Contraindicated in egg/soybean allergy
Midazolam 0.3 mg/kg 1-5 minutes May cause hypotension

Paralytics

Medication Weight-Based Dosing Time to Onset of Action Adverse Effects/

Contraindications

Succinylcholine 1.5 – 2.0 mg/kg 45-60 seconds Bradycardia. Malignant hyperthermia. Hyperkalemia.
Rocuronium 1.2 mg/kg 45-60 seconds
Vecuronium 0.1 mg/kg 2-4 minutes Questionable RSI utility when rocuronium available

Post-Intubation Sedation

Medication Weight-Based Dosing Notes
Midazolam 0.04-0.2 mg/kg/hr Short duration, but with long-term use has long half-life. Often used with fentanyl
Propofol 5-80 mcg/kg/min Propofol Infusion Syndrome with long term use: monitor TG, amylase/lipase
Dexmedetomidine 0.2-0.7 mcg/kg/hr
Ketamine 0.5-1 mg/kg/hr May decrease bronchospasm
Fentanyl 1-2 mcg/kg bolus25-250 mcg/hr

 

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Intubating the child

intubating-the-child

Endotracheal Tube Depth: Estimate

  • 3 x Internal Diameter of Endotracheal Tube (ETT) e.g. 4.0 ETT => Depth = 12 cm. Only used for ETT 3.0 or greater

Anticipate and Estimate, but Confirm with CXR!!!

 

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When intubation fails…

Intubation

We should never allow more than 3 intubation attempts, and sometimes clinical conditions will dictate fewer tries. Examples that come to mind are severe brain injury patients (hypoxia is bad) and patients who do not recover from oxygen desaturation when they are bagged. Don’t lose track of time and the number of attempts!

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