Some suggestions in terms of workflow for airway management.

The following  in an ongoing collaboration with Nick Caputo at Lincoln as we are attempting to develop a unified approach between sites to allow us all to learn from one another’s success and mistakes.  Check back frequently for updates as our supplies and what we know about the disease changes.

ED_COVID_RSI_Protocol v3-28


Ventilator shortage.  The hospital is facing a significant ventilator shortage.  In addition to our 7 VELA ventilators, there are 3 transport ventilators in radiology and 11 anesthesia machines in the OR.  1 transport ventilator should remain in radiology for use with patients requiring CT.  If OR ventilators are required, contact anesthesia for assistance in initial setup and questions.

We have 50 emergency transport ventilators with extremely limited capabilities.  Specifically, they are asynchronous and provide a maximum PEEP of 5cmH20 which makes them of limited value in the setting of severe ARDS.   The devices are a bit tricky to use, so look over the following visual guide and watch the video beforehand.  There is a ventilator in the admin office connected to a test lung and O2 cannister to practice with.

Instructions_VORTRAN Automatic Resuscitator VAR MODEL RC

Dual Ventilation Strategy

Dual ventilation strategy should only be considered as a last resort.  If attempting to do so, the following protocol may improve safety.

Ventilator-Sharing-Protocol-Dual-Patient-Ventilation-with-a-Single-Mechanical-Ventilator-for-Use-during-Critical-Ventilator-Shortages (1)

Non-invasive ventilation. In light of impending ventilator shortage, it is prudent that we avoid any unnecessary intubation.  If clinical history suggests that there may be a reversible component of failure (eg. CHF, asthma) then it may be reasonable to attempt at short trial of NIV.  A few guidelines for NIV:

-NIV should only be attempted with our closed circuit ventilators with a non-vented facemask.  The single limb dedicated BiPAP machines have a vent in the mask which will aerosolize droplets into the room when the patient exhales
-Attach HEPA filter at the mask prior to Y connection of the tubing
-Place patient in isolation tent
-Ensure tight mask fit prior to initiation of ventilation
-If albuterol administration required, administer via MDI adapter or aerogen nebulizer as pictured below



Any questions don’t hesitate to contact me anytime.  text/call 917-749-1004.