Equipment Notes

Whether to use bougies depends on the device you’re using. At Bellevue, we mostly used hyperangulated GlideScopes, so we didn’t use bougies. However, we did have some tube delivery problems with the hyperangulated GlideScope. When you have a heavier patient with a big tongue, sometimes you have problems with tube delivery with rigid stylets. In maybe two out of 15 cases, we switched from the GlideScope to direct laryngoscopy because of significant mouth restrictions. Physicians should rotate the hyperangulated blade around the curvature of the tongue and be very conscientious to avoid the secretion pool in the hypopharynx. In general, I think Macintosh shaped video laryngoscopes have easier tube delivery (especially with a bougie), and are best for handling secretions. These conventional shaped blades are now available from all the video laryngoscope manufacturers.

I don’t believe we should fiber-optically intubate COVID-19 patients through the nose. You can’t have patients nasally intubated for more than three days because they’ll get sinusitis, so anyone started on a nasal tube will need to be switched to oral. Awake nasal intubation also exposes you and everybody in the room to much more infectious aerosolization. RSI through the mouth is the only way to go.

Final Word

Remember to go slow and smooth. Go slow. Go smooth. One and done is best accomplished by slowing down and succeeding on first effort. Many patients will desaturate, but this seems to be tolerated more than in our usual RSI patients. Be careful with your introduction of the laryngoscope blade. Work your way slowly from uvula to epiglottis to laryngeal exposure to tube delivery. If you can’t get the tube on the first try, use an i-gel (or other supraglottic) attached to a viral filter. Bag the patient and switch to plan B. Safety first—be thorough and focused on proper PPE and minimizing operator and other team member exposures.

Acknowledgements: The real credit for the many lessons I learned and have since shared about COVID belongs to the ED physicians working in New York City for weeks before I arrived, who are still there weeks later, and who will be there for the long haul. I especially want to thank Dr. Nick Caputo and Dr. Reuben Strayer for allowing me to collaborate on their article in Academic Emergency Medicine, as well as “schooling” me about caring for COVID patients

Reference

1. Caputo ND, Strayer RJ, Levitan R. Early self-proning in awake, non-intubated patients in the emergency department: a single ED’s experience during the COVID-19 pandemic [published online ahead of print Apr. 22, 2020]. Acad Emerg Med. doi: 10.1111/acem.13994.