Brigham and Women's Hospitals

Procedures

Updated April 31, 2020

Bedside Procedures

  1. Procedures should not be performed by the primary team unless necessary: Please follow the flow chart above to find the relevant dedicated COVID procedure team.
  1. The COVID procedure team has in-house staff 24/7 (largely anesthesia, some surgical)
  2. Please notify anesthesia team at the time of intubation if you anticipate needing arterial or central access, as they may be able to obtain while in intubation PPE
  1. In the event that the primary team does need to do a procedure, please see these procedure protocols, page 20 for PPE and instructions
  2. While placement of a nasogastric or orogastric tube is not sterile procedure, it involves manipulation of the upper respiratory tract and requires the same PPE as for aerosolizing procedures (An N95 mask + face shield (or PAPR), bouffant hat, gown, and gloves)

Bronchoscopy

Indications

  1. Diagnostic bronchoscopy:
  1. BAL for COVID testing: Reserved for situations where:
  1. COVID-19 diagnosis would significantly alter management, and
  2. Less invasive specimens (e.g., nasopharyngeal swabs and tracheal aspirates) have been non-diagnostic
  1. BAL for secondary bacterial/fungal infection: Reserved similarly as above
  2. Inspection for localization of hemoptysis: Reserved for situations where:
  1. Radiographic imaging is unable to localize source (or unavailable), and
  2. Localization would significantly alter management
  1. Therapeutic bronchoscopy:
  1. Respiratory compromise due to:
  1. Hemoptysis, or
  2. Intractable mucus plugging (after failing less invasive measures)

Contra-Indications

  1. Unavailability of experienced operator
  2. High ventilator requirements and/or hemodynamic instability (use clinical judgment)

Preparation

  1. All providers:
  1. Ensure access to recommended PPE for aerosol-generating procedures
  2. Only essential staff should be present (conserve PPE, reduce staff risk)
  1. Bronchoscopist:
  1. Obtain informed consent per current institutional policy (i.e., verbal)
  2. Order labs
  3. Order paralytic agent: Recommend bolus dose based off actual body weight: cisatracurium 0.3 mg/kg, vecuronium 0.1mg/kg, rocuronium 0.6mg/kg, or atracurium 0.5mg/kg (use atracurium as last resort, and give it over 1-2min as it may cause hypotension)
  1. Nurse:
  1. Print specimen labels and place them in a biohazard sample bag
  2. Ensure patient is appropriately sedated + relaxed (if BIS available, target 40-60)
  1. Verify lack of cough on in-line suctioning
  1. A reverse Trendelenburg position (esp. if obese) may help prevent decruitment
  1. Respiratory Therapist:
  1. Ensure patient is getting mandatory (A/C or CMV) breaths (either VC or PC)
  2. Ensure patient has a secure airway (ETT or trach) with cuff inflated
  3. Ensure patient is preoxygenated with 100% FiO2 (for 10 min)
  1. Team should reconsider risk/benefit if SpO2 still <95% after 10 min
  2. Verify lack of triggering on vent (i.e., adequately sedated + relaxed)
  1. Gather materials:
  1. 3-way bronchoscope swivel adapter
  2. Suction tubing with attachment for wall suction
  3. 1 slip-tip 10cc syringe with 1% or 2% lidocaine drawn up
  4. 2 slip-tip 50cc or 60cc syringes with sterile saline drawn up
  5. Lukens trap or similar sample trap
  6. Silicone lubricant
  7. A chuck for placement of soiled bronchoscope immediately post-procedure
  8. Flexible bronchoscope along with the appropriate video monitor:
  1. Recommend disposable bronchoscope (no risk of cross-infection)
  1. Perform timeout/safety check

Procedural Steps

  1. Regular bronchoscopy:
  1. The most experienced operator should do the bronch, minimizing procedure time
  2. A nurse, RT, and dedicated assistant must be present throughout the procedure
  1. Technique for rapid bedside BAL (ONLY if patient can tolerate transient apnea):
  1. RT sets the vent in standby mode at end-exhalation (i.e., FRC)
  2. Bronchoscopist inserts bronch via swivel adapter and directly navigates to the target subsegmental bronchus, attaining a wedge position
  3. Assistant injects 50-60cc of saline
  4. Bronchoscopist applies suction to obtain BAL while NOT breaking wedge
  5. Assistant removes trap, applies secure cap, and connects suction to bronch
  6. Bronchoscopist removes bronch and wraps chuck around its distal portion
  7. RT resumes ventilator breaths and team ensures appropriate ventilation and stable vital signs before preparing to leave the bedside
  8. AT ALL TIMES, nurse monitors vital signs and asks team to immediately resume ventilation for hemodynamic instability, arrhythmia, or hypoxemia (SpO2<85%)

Post Procedure

  1. Monitor for pneumothorax post-procedure (esp. in cases with high airway pressures)
  2. Make sure the patient remains on a mandatory ventilation mode until paralysis wears off
  3. Place specimens in biohazard bag(s) with labels and call to notify the lab ahead of time
  4. If a disposable bronchoscope was used, dispose it off in a biohazard bin
  5. Follow standard High-level Disinfection protocol for re-usable bronchoscopes
  6. Follow standard disinfection protocol for video monitors and bronchoscopy towers
  7. Follow PPE doffing protocol
  8. Write procedure note in Epic
  9. Routine CXR not needed but may be obtained if desired (use clinical judgment)

Intubation in the Emergency Department

  1. Please see the current Emergency Department Intubation Protocol

Intubation in ICU or Floor

Preparation

  1. Treat all floor/ ICU/ ED intubations as a presumed COVID positive patient
  2. Intubating with the necessary PPE is often unfamiliar/difficult to many providers - consider practicing via simulation (APSF Considerations for Airway Manipulation, 3/20/2020). Our current recommendation includes disposable hair bouffant or cap, eye protection (face shield only vs face shield AND protective eyewear), either N95 or PAPR (N95 + hood for neck protection), fluid resistant gowns (blue impermeable), double gloves, leg protection (boot covers) to below the knee These recommendations exceed the standards of the American Society of Anesthesiologists on 3/20/2020, the Society of Critical Care Medicine on 3/20/2020, and the Anesthesia Patient Safety Foundation on 2/12/2020
  3. Collect Materials in advance:
  1. Airway boxes (nasopharyngeal airways, oral airway, syringes, needles, LMA’s, blue “bougie” stylet, extra ETT’s 6.0-8.0)
  2. Medication boxes(paralytics, phenylephrine, ephedrine, epinephrine, lidocaine, labetalol, esmolol, propofol/etomidate, midazolam)
  3. Dedicated video laryngoscope.
  1. With the exception of the video laryngoscope, DO NOT take these boxes into the room - only remove what you may need and discard materials taken into the room after intubation even if not used
  2. ICU Ventilator set up:
  1. Place HEPA filter between patient and EtCO2 monitor to avoid contaminating sample line(mandatory)
  2. If available, place HEPA filter on expiratory limb closest to the ventilator (preferred)
  3. If EtCO2 monitor utilizes infrared measurement(i.e. Does not actually pull sample gas into machine) then may utilize single HEPA filter either between ETT and Y-piece or at expiratory limb closest to ventilator
  1. Rapid Sequence Induction(RSI) should be performed by the most experienced airway provider using a video laryngoscope(SCCM COVID19 Guidelines)(APSF Considerations for Airway Manipulation, 3/20/2020)
  2. Limit providers in room to 3: 1 airway team member(s), respiratory therapist, and registered nurse
  1. Assign roles and airway plan (who will “hold/do” what)
  1. Perform a “pre-induction” checklist prior to starting:
  1. Suction available
  2. Audible pulse oximetry
  3. NIBP cycling
  4. Ventilator setup and ready with quantitative EtCO2 monitor in-line and ready (avoid color change device if possible)
  5. Free-flowing IV access
  6. Post-intubation sedation ready
  7. HEPA filter in-line
  8. Medications ready
  9. Non-rebreather, flow “OFF” until ready to preoxygenate
  10. If no ventilator is available, ambu bag post intubation with HEPA filter, +/- CO2 detector. Flows turned down during circuit changes
  1. Ensure patients are in negative pressure rooms for all intubations/extubations(SCCM COVID19 Guidelines). Negative pressure rooms remove viral aerosolized particles at different rates based on the air changes/hour(ACH). OR’s are mandated to achieve at least 15 ACH’s yielding 99% airborne viral removal in 18 minutes. This is different for ICU’s and you may want to contact your facilities engineers to clarify ACH for your ICU beds. Calculate time necessary for your facility following CDC guidelines(CDC Negative Pressure Airborne Clearance Times) and facility recommendations

Procedure

  1. Don appropriate PPE via “read/do” checklist, gather supplies and review airway plan
  2. Preoxygenate the patient: maintain preoxygenation technique until neuromuscular blockade has set in
  1. Option 1: 3-5 minutes of tidal breathing 1.0 FiO2 on non-rebreather at 15L/min flow
  2. Option 2: facemask attached to AMBUbag with HEPA filter (2 hand technique to maintain seal)
  3. Option 3: if patient already on BiPAP then maintain BiPAP with tight seal until ready to intubate(turn “OFF” BiPAP flow prior to removing mask)
  1. Intubate the patient with an RSI technique/video laryngoscopy
  1. use awake intubation only when absolutely necessary as deemed by attending anesthesiologist
  1. If mask ventilation becomes necessary:
  1. use 2-hand technique with oral airway to create tight seal
  2. use AMBUbag with HEPA filter in-line with high frequency/low tidal volume
  3. do not remove mask for 2nd attempt intubation until end exhalation
  1. After successful intubation:
  1. Inflate cuff
  2. connect patient directly to ventilator with HEPA filter with EtCO2 gas sampling line post-filter or use an infrared CO2 analyzer with no gas sampling
  3. confirm via quantitative in-line EtCO2 (gold standard > 3 breaths), bilateral chest rise, “fogging” of ETT, cuff palpation and possibly increasing SpO2
  4. avoid listening bilaterally for risk of contamination(touching ears with stethoscope/hands)
  5. secure ETT per hospital policy
  1. Clean the laryngoscope:
  1. Remove soiled gloves and replace with clean gloves
  2. Clean the video laryngoscope and allow it to dry - 3 minutes if PURPLE Sani-Cloth(Sani-Cloth Technical Sheet).
  3. Push video laryngoscope out of room with clean gloves on
  1. Follow “read/do” instructions for doffing of PPE per hospital protocol

Intubation in Operating Room (COVID positive or suspected)

Preparation

  1. If possible, intubate the patient via dedicated airway teams in a negative pressure room in the ER or ICU in anticipation of surgical intervention. This allows for a closed circuit during transport and minimizes transmission
  2. Anesthesia Machine set up:
  1. Place HME filter between patient and in-line EtCO2 monitoring(APSF Anesthesia Machine Protection) then place a HEPA filter closest to the anesthesia machine on the expiratory limb as shown below
  2. May also consider adding another HEPA filter closest to the patient before HME filter if your facilities HME filters are not VFE > 99.99% rated
  1. Ensure OR is set to be on negative pressure
  1. hang signage to prevent unnecessary entry
  1. 3-person team is the preferred method:
  1. Intubator - most senior provider, will manipulate airway only
  2. “Clean anesthesia provider” will manipulate anesthesia machine, administer medications, chart, and read checklists
  3. Circulating RN as assistant to intubator
  1. Perform routine anesthesia machine check and pre-induction checklist:
  1. consider removing all medications you may need for entire case to minimize omnicell contamination/movement in and out of room
  1. Gather supplies:
  1. Place ETT, airway adjuncts, temperature probe, OG tube, eye protection, bite block and tape in a basin and hand to circulating RN positioned at side of bed
  1. Position equipment:
  1. video laryngoscope plugged in and working within reach
  2. trash cans open and near table

Procedure

  1. Personal Protective Equipment:
  1. don appropriate PPE via “read/do” checklist prior to entering OR
  1. Transition patient to OR oxygen delivery
  1. Move patient to OR table
  2. If patient has supplemental O2 (i.e. nasal cannula) then continue until ready to pre-oxygenate with anesthesia machine. Ensure flow of supplemental O2 is turned “OFF” before manipulating device
  3. The “clean anesthesia provider” ensures APL at “zero” and all flows “OFF”2, remove patient facemask and immediately use 2-hand technique to place circuit face mask on patient
  1. Preoxygenate:
  1. Turn O2 flow to 2L/min and allow patient to preoxygenate for 3-5 minutes at tidal breathing to minimize facemask leak that may occur with vital capacity breathing
  1. Intubate:
  1. “Clean anesthesia provider” will push RSI medications once preoxygenation is complete.
  2. Avoid hand ventilation if possible. If hand ventilation needed, intubating provider to maintain 2-hand mask and “clean anesthesia provider” will touch bag/APL valve
  3. “Clean anesthesia provider” turns off gas flows
  4. Intubating provider disconnects facemask and place next to patient’s head, and uses video laryngoscopy to intubate patient
  1. After successful intubation
  1. Circulating RN pulls stylet, intubating anesthesia provider occludes end of ETT with finger, circulating RN inflates cuff, and then connects circuit
  2. “Clean anesthesia provider” turns on gas flows and ventilator and confirms EtCO2(gold standard > 3 breaths with consistent waveform and value)
  3. intubator monitors for bilateral chest rise and “fogging” of ETT
  1. avoid listening to breath sounds as can cause contamination of providers
  1. Circulating RN will take control of ETT while the intubating provider tapes
  2. Intubator will place OG tube, temperature probe, eye protection and bite block
  3. “Clean anesthesia provider” will start appropriate anesthetic i.e. inhaled volatile vs TIVA and chart as needed
  1. Clean equipment:
  1. Intubating provider and circulating RN will change top gloves with and then clean video laryngoscope/any other equipment that may have been contaminated
  1. Allow 18 minutes to facilitate 99% aerosolized virus removal(assumes ACH of 15/hr) from time of intubation then allow other OR personnel(i.e. Surgeons/scrub tech) into the OR with proper PPE

Transporting from the OR to the ICU

  1. Place HEPA filter between patient and Y-piece to prevent viral contamination of circuit
  2. Maintain patient in a negative pressure environment with PPE including N95 or PAPR prior to transitioning to transport ventilator
  3. Clamp ETT, remove from anesthesia circuit and then place onto transport ventilator.=
  4. Unclamp the tube and confirm ventilation. If EtCO2 monitoring is used for transport, ensure it is POST HEPA filter(EtCO2 closer to ventilator)