Oxygenation and Ventilation Strategies
“Reducing risk of aerosolization during the process of intubation is key,” Sasson emphasized.
For this reason, a high-efficiency particulate air HEPA filter (if available) should be attached to any manual or mechanical ventilation device, specifically in the path of exhaled gas, before any breaths are administered.
Moreover, it is important to intubate early with a cuffed tube and connect to a mechanical ventilator, if possible. The intubator should be engaged with the “highest chance of first-pass success,” and chest compression should be paused to intubate.
To further increase the chance of a successful first intubation, use of video laryngoscopy (if available) is helpful.
Additional guidance includes:
- Using a bag-mask device (or T-piece in neonates) with a HEPA filter and a tight seal prior to intubation
- Considering passive oxygenation with non-rebreathing face mask as an alternative to bag-mask device for short duration (in adults)
- Considering supraglottic airway if intubation is delayed
- Minimizing closed circuit disconnections.
Resuscitation Considerations
“One big take-home point of the guidance is to consider resuscitation appropriateness, starting with goals of care when the patient comes to us, and continuing or stopping resuscitation when needed, based on the discussion with the family as well as local protocol,” Sasson said.
A variety of factors need to be taken into account, including age, comorbidities, and illness severity to determine the appropriateness of resuscitation, and “the likelihood of success” must be balanced “against the risk to rescuers and patients from whom resources are being diverted,” the authors state.
An Array of Scenarios
“We divided bystander CPR into adults vs pediatrics and into those who are living with a person who is in cardiac arrest – because they have already been exposed [to COVID-19] – vs those who are not living with the patient,” Sasson reported. “We also addressed the role of lay bystanders.”
For lay rescuers:
- Household members should perform at least hands-only CPR, if willing and able to do so
- Use of a face mark or cloth covering of the mouth and nose of the rescuer and/or patient may reduce the risk of transmission to a nonhousehold member
- In children, lay rescuers should perform chest compressions and “consider mouth-to-mouth resuscitation,” especially if they are household members.
- If available, an automated external defibrillator should be used to assess and treat victims of out-of-hospital cardiac arrest (OHCA).
The authors offer additional guidance for in-hospital cardiac arrest (IHCA), including addressing advanced care directives, closing the door when possible to prevent airborne contamination of adjacent space, and considering leaving the patient on a mechanical ventilator with HEPA filter.
They additionally address the special needs of neonates, recommending the presence of a “skilled attendant prepared to resuscitate, irrespective of COVID-19 status,” and stressing the importance of PPE since the mother may be a “potential source of aerosolization for the neonatal team.” Additional measures include avoidance of routine airway suctioning and the use of endotracheal medications.
Critically ill pregnant women with COVID-19 are more vulnerable to acute decompensation because of the cardiopulmonary physiological changes associated with pregnancy, the authors note. Preparation for a potential perimortem delivery should take place after 4 minutes of resuscitation and be initiated early in the resuscitation algorithm so as to allow specialized obstetrical and neonatal teams with PPE to convene.
“We will be continually updating this guidance and we are encouraging people to ask questions,” Sasson summarized.
She noted that a hospital-based COVID-19 registry is being formed to collect “clinically relevant data” that will inform and update the current guidance.
Sasson reports no relevant financial relationships. The other authors’ disclosures are listed on the original paper.
This article first appeared on Medscape.com.