Extubation of patients with COVID-19

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The following article focuses on the various recommendations for anaesthetic management of patients with COVID-19. The guidelines describe techniques for safe tracheal intubation using rapid sequence induction. As extubation is an aerosol generating procedure, commonly associated with coughing and requires close proximity of the anaesthetist to the patient, it is recommended that pre-extubation planning is practiced.

The article also focuses on the correct technique to follow during extubation, post-extubation and the complications associated with it.

Significantly, patients requiring intubation for respiratory failure or emergency surgery are likely to remain infective at the time of extubation. Leaving COVID-19 patients intubated after emergency surgery provides the best protection against coughing and aerosolization.

Detailed Summary 

Pre-extubation Planning Guidelines

  1. Extubation should take place in a negative pressure room, if available.
  2. All non-essential staff should exit the room prior to extubation.
  3. PPE with airborne precautions are required during extubation, and for personnel entering the room for at least 30 min after extubation.
  4. Prophylactic antiemetics.
  5. Adequate analgesia, consider regional anaesthesia.
  6. Perform oropharyngeal suction with vigilance as this may generate aerosols.
  7. Antitussive drugs such as remifentanil, lidocaine and dexmedetomidine reduce the risk of coughing and minimise agitation on extubation.

Extubation guidelines

  1. Position the patient 30o head up.
  2. Anaesthetist and assistant positioned behind the patient’s head, attempting to avoid exposure to any coughing.
  3. Optimise anaesthetic facemask seal (prior to induction of general anaesthesia the anaesthetist will have ensured correct facemask size, adjusted inflation of mask cuff, shaved any facial hair).
  4. Attach a second airway filter to the facemask. The CO2 sampling port should be capped.
  5. Position the tracheal tube (TT) to one side of the mouth, closest to the anaesthetic assistant’s position for extubation.
  6. Position the facemask with a second airway filter, using a two-handed technique to ensure a seal over the mouth and nose with the TT exiting under the facemask.
  7. No positive airway pressure during extubation: ventilator off with no or low fresh gas flow. Consider attempting to extubate at end-expiration.
  8. Deflate TT cuff and extubate while maintaining facemask seal.
  9. Discard TT and connect the circuit to the second airway filter facemask to the anaesthetic circuit (in the OT) or the non-rebreather valve of a self-expanding bag (in the ICU).
  10. Maintain a two-handed mask seal until regular breathing via the circuit and any immediate post-extubation coughing has subsided.

Post-extubation guidelines

  1. Place a surgical mask on the patient once the anaesthetic facemask is no longer required. Supplemental oxygen can be delivered under a surgical mask via nasal prongs.
  2. Staff members should confirm that PPE integrity has been maintained.
  3. Doffing should only occur once the patient has been handed over to another staff member. The room requires airborne precautions for at least 30 min after an aerosol generating procedure such as extubation

Complications

  1. The ability to communicate and make rapid changes to plans is inhibited by PPE. Therefore it is critical that the airway team discuss possible complications and plan specific roles prior to extubation.
  2. If laryngospasm occurs, consider early use of pharmacological agents to treat the spasm and avoid or minimise need for positive pressure ventilation.

If apnea occurs after extubation necessitating positive pressure support, consider bag mask ventilation with a two-handed technique, attempting to minimise positive pressure with small tidal volumes.

Reference Link : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144617/

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