SPEAKER: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc., and is in accordance with ACCME guidelines.

ALEX NIVEN: Welcome to the Mayo Clinic Critical Care Insights: COVID Edition. My name is Alex Niven. I'm a consultant in the division of pulmonary critical care and sleep medicine here at Mayo Clinic in Rochester, Minnesota. And also the education chair for both our division and for the independent multi-specialty critical care practice.

The COVID pandemic has changed the way that we practice-- likely forever. And the critical care community has been particularly impacted by the current pandemic. Critical Care Insights: COVID-19 Edition is intended for healthcare providers who are caring for patients with COVID-19 across the world in the ICU.

Best practices to care for these patients have been rapidly evolving and busy bedside providers-- I know I have-- struggle to keep up with the volume of information, especially given that the information sources that have been providing it are frequently less than rigorously peer reviewed. In response, Mayo Clinic has developed an AskMayoExpert COVID-19 task force that have collected and curated the available contents into a free public website under the Mayo Clinic AskMayoExpert COVID-19 navigator.

This source provides, basically, a curated site for best practice recommendations in the care of COVID-19 patients, developed collaboratively by an interprofessional stakeholder group of Mayo Clinic subspecialists. And this information is continuously informed by rapid literature scoping reviews performed by the Kern Center for the Science of Health Care Delivery.

This online CME course is designed to speed dissemination and implementation of these best evidence-based guidelines; best practice innovation; and provide discussion of ongoing clinical controversies that we face in critical care, as we take care of these patients. These discussions will feature the original authors of the content that is available on AskMayoExpert and allow them to discuss the evidence and best practices that they have used to provide these recommendations and the why behind the information that they've shared.

We will be continuously updating this content as time goes on, based on the available high quality evidence that comes through our rapid scoping reviews and our evolving innovations and evolution of clinical practices within our own health care delivery platform here at Mayo Clinic.

This initial CME offering consists of seven lectures including topics from intubation safety, infection control, workflow considerations, navigating drug shortages, maximizing team performance, mindset training for the individual, humanizing critical care, respiratory therapy innovations, among others. We will continue to evolve this content as time goes on with new information on the epidemiology; virology; clinical features of COVID-19 patients; and also evolving recommendations with regards to testing and the care, in addition to infection control considerations in this challenging population.

We hope that you enjoy this work. This information has been provided as a series of Grand Rounds presentations to our critical care community over the course of the last five weeks, and will continue to evolve over time. Welcome to Critical Care Insights. I hope you enjoy our work.

Welcome to a Critical Care Grand Rounds and thank you for joining. My name is Alex Niven, education chair for the IMP. We have another distinguished panel of guests here today, and the topic that we are going to discuss today is airway management practices in the COVID pandemic. But before we start, what I'm going to do is--

So we were talking before we started here about the bad TV that a COVID air cut and a mask makes. So we will try to maintain appropriate posture here and appreciate any feedback from folks who are watching. If the audio is less than ideal with masks then we'll adjust things accordingly, because I think it's important for people to be able to hear these conversations. Before we get started I'd just like to go around the circle and have everybody else around the table introduce themselves, because some of these faces are not ones that run every day in critical care circles. Steve.

STEVE GLEICH: Well good afternoon, everybody. And Alex, thanks for the invitation. I'm Steve Gleich. I'm a pediatric intensivist and anesthesiologist here at Mayo, and I appreciate the opportunity to work on the airway management stuff with everybody here.

BEN DAXON: I've Ben Daxon. That's what I look like. I'm one of the anesthesiologists here. I also work in the ICU. And what more do you want from that?

TANNER HILL: Hey, everyone. I'm Tanner Hill. I'm one of our respiratory therapy supervisors. I'm charged with our emergency department in trauma ICU groups.

BEN SANDEFUR: And I'm Ben Sandefur. I'm one of the emergency physicians here at Mayo Clinic in Rochester. And I really appreciate the opportunity to be involved with you guys.

ALEX NIVEN: Yeah, we've spent an awful lot of time together over the course of the last couple of weeks-- at least virtually. So it's exciting to actually meet some of these folks face to face for the first time. So just a few rules of the road before we start the conversation. Just like last week, if you are in front of a computer please go to the main Mayo home page. The search box in the top right corner-- if you don't have it bookmarked. You can just type in CC space IMP. I-M-P. That'll take you to the critical care IMP site.

And you'll see a big red box on the right hand side of the page that says COVID Corner. Click on that box. When you open up the COVID Corner, the tab down at the bottom that says acute best care management practices-- something like that. Click on that. Actually, it's acute care best practices. I'm sorry. I've got it right in front me. Endotracheal intubation is the fifth line down. And what we're going to be talking about here is basically the core principles and the flow charts that are listed under that bar.

So I have two anesthesiologists here. And it would be remiss for me not to start with the airway experts when it comes to why we're so concerned about endotracheal intubation in the setting of the COVID pandemic. So Ben, Steve-- lead away.

BEN DAXON: Sure. Obviously these patients require some forethought, and everybody has a different approach to how they like to do intubations. Our thought process was to try and bring a lot of different people and minds together and think what would be some best practices that we could all apply. I think uniformity would help here. Obviously, you'll individualize it to the patient and your individual abilities. But I think for safety and consistency, it'll be helpful if we had a shared common document that we could deviate from if needed.

But it's a shared common place to start from. That's really what this is. A lot of people had input into this. I got a lot of emails over the last two weeks. Not every idea is included. I can't do all of that. It's a lot of information. Just for reference, this started out as three pages. We've whittled it down to one. But even on that one page, it's still quite a lot.

One of the things we hope to achieve with it-- because there is a lot-- was to have a checklist. These will probably be stressful situations. And so things can easily be forgotten when your heart rate's pounding a little faster than normal. So it's a nice reference tool to go through and systematically think about how you're going to approach an innovation; what supplies you need, what steps you need to take, and little things that might be forgotten and that might be different with a COVID patient.

ALEX NIVEN: Steve, anything you'd like to add?

STEVE GLEICH: No, I think that's a very good summary. I don't have anything else specific to add.

ALEX NIVEN: Perfect. I'm going to move to Ben next. Ben Sandefur. I've got to be careful, because I've got two Bens in the room. Because, truthfully, Ben was way out in front in terms of developing a lot of the content for this. So I think it would be only appropriate to start with him in terms of the reasons why you started putting this together and then the initial thought processes and considerations that went into the initial draft document that then you circulated to us.

BEN SANDEFUR: Thanks, Alex. So I think it's important to note that there's a lot of information out there. I would assume most people who are on the call have read the WHO interim guidance at least, as well as probably many other documents. Safe Airway Society, Difficult Airway Society from Royal College of Anesthesiologists in Great Britain. Varied groups have put out lots of documents over the past one or two months. So there's a lot of guiding principles out there.

And one of the challenges really becomes, how do you synthesize the information that we know and turn that into something usable for an institution? So that as we go to intubate patients here at Mayo Clinic, I know what Dr. Gleich is doing. Dr. Daxon knows what we're doing, and we have a common shared understanding of how to apply these principles.

So one of the things that we really wanted to do from the beginning was just lay out our guiding goals. And I think those are two things. One, we want safe care of patients during tracheal intubation. That's an unchanged goal that has existed for forever, and we're going to keep that as number one. And then second is safety of the patient care team, which has really taken a new area of importance within the COVID pandemic. And I think that those two goals are really informed by three core principles.

And you'll see at the top of the document that we've collaboratively put out here-- there are three things that really stand out. It is decreasing aerosol generation, decreasing exposure risk, and prioritizing personal protection; and then maximizing your first pass successes. So everything that we've tried to synthesize really comes back to one of those three things. As Dr. Daxon was pointing out earlier, we can't make a checklist that accounts for every circumstance we're going to encounter. But as long as we're thinking back to those three principles when we're making decisions at the bedside, we're probably going to make the best decision-- even if there's not a right decision.

The last thing I'll say is, I think there are a couple of things that have really changed as a result of COVID pandemic that really stresses us to think about how we walk through our tracheal intubations. One is the concept that you have to have everything out and ready and have your plan fully thought out, even more than we normally do. Because we're not going to have an airway part that we can go sticking our hand into right beside us, if we've already been touching mucous membranes, because that's going to contaminate everything within our environment.

The second one is, in the event you don't achieve a first pass success typically we've immediately gone to mask inhalation. And that's been a longstanding principle that we can utilize mask inhalation to oxygenate someone and ventilate them in the event of failure, or even using that as a pre-oxygenation technique. And here we're in a circumstance where it may be mask inhalation is potentially deleterious to us as care providers, because of aerosol generations. You're going to see some new things in there such as early placement of superglottic airways, which are not really part of usual practice.

And then lastly the concept of ventilator circuit disconnects and really trying from the very get-go to avoid disconnecting the circuit. And if we do disconnect the circuit, we need to be really regimented about how we do it to prevent aerosol generation. And so those are kind of three big things that stand out in my mind as changes to our usual process that I really have to think through every time I go through this to be sure that I'm not violating those principles.

ALEX NIVEN: And just to reiterate and add a couple of those points. I think we all acknowledge the fact that airway management is probably the highest risk procedure that we do in the intensive care unit, in terms of the potential adverse sequelae on patients. It is a high risk, aerosol generating procedure-- or ATP-- which, ironically, two weeks ago I think that acronym was foreign to me. But that's what it is.

Really, the core things that we know in terms of adverse outcomes for airway management in the ICU-- planning, preparation, and teamwork are really the primary failure modes. So that's one of the reasons why we're being so deliberate in terms of identifying and thinking about how to address those issues, because we want that first pass success to be high. And we want to make sure that we minimize risk posed to the patient and to the team as we go through that process. Ben, if you don't mind, I'm going to go back to you to start off with.

BEN DAXON: Can I interject--

ALEX NIVEN: Oh yes, please.

BEN DAXON: There's a question that just came up. Could you just repeat for me how to access the document?

ALEX NIVEN: Yeah, absolutely. So if you are in front of a computer, you want to go to the Mayo home page on the internet. The top right corner is where the little search bar is there. You type C-C space IMP. I-M-P. That right hand bring up the critical care IMP web page. Click on that. On the main web page, there is a red box on the righthand side that says COVID Corner. Click on that box. Click on the tab, sort of halfway down the page, that says Acute Care Best Practices. And the endotracheal intubation bar is the fifth bar down. Click on that to open it. And you'll see the key take home bullet points, along with both the adult and the pediatric intubation guidelines that we've put together.

And again, this has been a consensus effort with multiple different stakeholders, not just the folks around the room. And this continues to be-- the final revision of this-- continues to be circulated through anesthesia and perioperative medicine. And as with most of the other things on the COVID Corner, this is a current guideline that will continue to evolve as we gain more maturity taking care of these patients and more of a collaborative understanding of what that entails.

I will say as well, one of the things that I think we all struggled with was the right level of detail to provide in this document. This is meant to be a guideline trying to provide something for everyone. I think it's challenging. Experienced airway managers may look at this and say, wow, there's a lot of detail here that maybe I don't need. Maybe folks that are not as experienced airway managers who potentially are out in the health system or in small access hospitals might look at this and say, I need more. So that was something that we debated a lot, and I'm sure we'll continue to debate as we go forward with this thing. So with that disclaimer, we'll dive into it.

I guess from a process standpoint, who should make up an airway team? Who should be doing this? And how do we decide how to jump down this algorithm, is a place to start. And I'll just open that up to anybody.

STEVE GLEICH: Well, I think it's ideally the most experienced person who has the most-- certainly the most training-- but also the most experienced in getting the tube in on the first time. So maximizing your first pass success would be one goal of the team. And then other general principles-- just trying to keep the team lean, meaning that you want as few people in the room as possible because this is certainly one of the highest risk procedures to expose the healthcare providers to. Nosocomial infections and we really want to try to limit the number of providers in there.

BEN DAXON: It'll vary a little bit too. So in the OR, for example, they're just doing two people right now because the anesthesiologist and CRNAs are used to immediately hooking up the patient to the ventilator. That's not something I routinely do in the ICU. So we would do three people in the ICU; two experienced airway operators and a third respiratory therapist to help out with medication administration and hooking up to the ventilator.

So part of it too will depend on the context. And again, we'll emphasize this throughout the Grand Rounds here-- these are guidelines. You'll have to fit them to your particular area.

BEN SANDEFUR: I think the vast majority of patients in the emergency medicine setting, as you guys have articulated, a three person team is usually ideal. There may be circumstances where, because of patient characteristics-- morbid obesity, someone who you're concerned about a very difficult airway from the beginning that you think an extra set of hands is going to help you achieve a first pass success. And there you're balancing, what is the downside of a failure of first pass which is going to lead to potential poor patient outcomes-- peri-intubation adverse events. As well as a need for a second attempt, which is another aerosol generating procedure versus the downside of having a fourth or fifth person in the room. So these are very context dependent.

And as Dr. Daxon was saying, these are really guidelines. We don't want people thinking that they can only have three people in the room. But you have to be thoughtful about who you have in the room. And kind of getting to what you were discussing earlier, Alex, about this being a high risk procedure for patients. I think it bears stating that it's also a high risk procedure for providers.

The data that comes out of the SARS epidemic from a decade or more ago would suggest that there's a five to 13-fold increase risk in nosocomial transmission to the proceduralist who are at the bedside within six feet of the patient as compared to other health care providers who are caring for patients. And that includes people who are receiving non-invasive ventilation techniques like BiPAP, CPAP, high flow nasal cannula, things that we're all worried about right now as well. But it bears stating that this is probably our highest risk procedure to us as providers.

ALEX NIVEN: So I think without getting too deep into who do we intubate, when do we intubate-- because I think that that's still a very evolving area within the literature. Our strong bias is that we want to make sure that we're prepared early, that we're diligently applying our PPE appropriately. And we've talked back and forth about runners outside of the room and all that stuff to make sure that we have appropriate resources. How about a difficult airway? Let's say I've got that person who's really large, has a beard and some other things that might make them a difficult airway. I'm going to look at Ben here, but I guess I can look at Ben and Steve in terms of, what's the best thing to do in terms of engaging the difficult airway team?

STEVE GLEICH: I think recognition that there may be a potential for a difficult airway, even a high potential for difficult airways is key. And then calling early. That's probably one of the things we try to highlight very, very early on in our checklist here. And we list-- at least at St. Mary's and Methodist-- we list numbers that are available to call to have somebody there to support you. And I think it all comes down to the planning too. Once setting up these plans in place, before even entering the room, is vital.

BEN SANDEFUR: I would agree. I think at no time during tracheal intubation of any patient is hubris indicated-- and probably less so now. So this is the time when you really try to accurately identify where your potential weaknesses are. And if you have an individual that's going to have a potentially difficult airway-- this is a load the both situations. You want to have your backups.

In our case in the emergency department, we have excellent anesthesiology colleagues who come at a moment's notice and will engage in a collaborative plan for what's the best way to achieve tracheal intubation in this patient. If you're in a health system site or you're in somewhere where you don't have that luxury of backup, there oftentimes still are other options. Whether that be the medic crew that's down the road or the flight paramedic that's five minutes out. Maybe it bears waiting until they land so that you have an extra set of hands to be able to manage that.

ALEX NIVEN: Just to echo-- and I think this is a point that Ben Daxon brought up during our discussions. I'm spoiled by having the difficult airway consultant so rapidly responsive in my practice setting. The thing that's different here is, they've still got to get dressed with a BP.

As I've thought about this, I've thought more and more about preemptively calling those folks before I start going in and doing stuff if I'm really concerned, because there's no harm. They can stand outside of the room all dressed up, ready to go if I get in trouble. All right. Let's talk about planning preparation when it comes to patient and equipment going in the room.

We've talked about PP in general terms, just to be explicit? What are we talking about in terms of the dress up? Tanner, what are you guys doing in terms of high aerosol generating procedures for RT?

TANNER HILL: For PPE, we would be donning our N95 mask. We would include a face shield, which in the EED we've been using a reusable device for face shield, gown, and we're telling folks to double glove now as well. That would be kind of the standard there for intubation procedure.

ALEX NIVEN: Ben Daxon, you've added some substantial things to the conversation in terms of the types of equipment to bring in the room. So what sort of things were you thinking about when you were making those suggestions?

BEN DAXON: What are you most comfortable with? We try to keep things, again, vague here. UD has a lot of experience with the King LMA. We don't use that quite as much in anesthesia. We're more Air-Q people. So we, again, try not to box people in. I would just fall back to whatever you're most experienced with.

Again, maximizing first pass success is one of our guiding principles here. So if it's a technique that you're more confident with that you think will get your first pass success, that might be better than something you're not as familiar with. It seems like it's a good idea, but it's just going to result in you taking two attempts rather than one attempt. So, again, these are all judgment calls to make. You'll just have to think through it for yourself.

BEN SANDEFUR: Comment on that. I think that's a principle that very much bears reiterating. That idea of falling back on your comfort zone is important, because you're kind of seeing a categorical recommendation of video laryngoscopy here. And that's for good reason, because you have increased face to face distance if you're doing VL as opposed to a direct laryngoscopy technique. A new paper just came out in the past week where they essentially just measure distances between faces and they found that's indeed correct.

But if you're someone who trained in the era before hyper emulated video laryngoscopes were introduced and your comfort zone really is direct laryngoscopy or standard geometry blades, this again becomes a point where you have to balance the risks of both. Right? What's the risk of failure to delivery on the first attempt with use of a device you're not as familiar with? Versus the risk of using direct laryngoscopy and trying to maintain as much face to face distance as you can. We're fortunate in the ED to have a CMAC for educational purposes. So we have a standard geometry video laryngoscope, but that's not available in all care locations.

STEVE GLEICH: I'm going to dovetail on that. This point is especially true of children. Now, we're a bit lucky in pediatrics in that the prevalence of severe disease of COVID in children is very, very low-- probably at least a tenth of what it is in adults. And a lot of the reports coming out of China say that critically ill children may make up less than one percent of all cases. So the number of critically ill children we're seeing is pretty darn low. But the point about using your preferred intubation technique is really important, especially in younger kids.

We've seen that infants and smaller children may be at a bit more risk of severe disease with COVID. And those are age groups where especially the hyperangulated video laryngoscopes are a bit tricky to use, in that there is a bit of an anatomic mismatch between the standard GlideScope blades that we have and in infant airway anatomy. As such, a lot of our providers are far more comfortable utilizing direct laryngoscopy, especially for that age group. That's one thing we try to highlight in the pediatric version is, use what you're most comfortable with, what you're most experienced with, because the principle of maximizing first pass success is really critical here.

ALEX NIVEN: Just to chime in there. So there was a retrospective review of big databases compiled by eight large academic centers. It was published, oh gosh, about a year and a half ago or so. Where they actually looked at-- and this is in the operating room-- can't ventilate, can't intubate emergency airway situations where usually the guidelines are pretty simple. Right? Place an extraglottic airway in that sort of situation. 80 percent of the time-- and again, this is retrospective data-- they used GlideScope with actually a very high rate of success. You train as you fight. So the things that we feel comfortable using are probably the things that we're going to perform the best with.

The other thing that I would highlight-- and maybe I'll hit Ben on this a little bit later-- is practicing with these new guidelines is super important before you find yourself in the midst of all that. I did just get one question through a non-standard route. There was a question about basically covering up the head and neck which certainly has been out there in some of the postings and discussions.

I guess I'll lump with that the clear drape over the patient or the box over the patient. All of these things are, I think, emerging concepts to try to reduce the risk to providers in terms of aerosol exposure. It's still not currently recommended by our IPAC folks. But there's lots of people actively working on this. I know in the department of anesthesia and in respiratory therapy and I'm sure in others areas as well. So with that, we've talked a little bit about PPE. We've talked about devices. Ben, can I hit you up just for a minute to talk about your map? Because I think that that's a really cool innovation.

BEN SANDEFUR: Yes. So my colleague, David McAlpine, who is one of our practice leaders in Austin Albert Lea and also a practitioner here in Rochester, has worked with some of our folks from anesthesiology in the health system to develop essentially a cognitive guide, which is a map or a mat that will lay on a table. It has laid out on there exactly what devices you're going to need for your first attempt and for your backup.

We're currently not using this in Rochester. We're using more of a bagged system-- a bag with your first round of devices for first intubation attempt. A second bag with your superglottic devices, your scalpel, your six OET tube in the event that you need to get into a backup scenario. And that bag can be wiped down with Oxivir between attempts. I think it really depends on your practice setting. What works best for you as cognitive aid in order to know that you have all the right equipment at the bedside and at hand? Particularly in areas where intubations are not performed as frequently, I think having cognitive aids that are very depictive can be additive.

ALEX NIVEN: Yeah. I think that's nice. So we've talked about planning. We've talked about preparation of ourselves. We haven't necessarily talked a lot about patient preparation. For anybody, what are the things that we should think about while we're getting organized? We've got all dressed up. We've got a patient who looks like they need intubation. We've brought the supplies in the room.

And I guess I'll just add a point that Ben Daxon made along the way, which is if we're intubating somebody here we're probably thinking about lining them in terms of central line and arterial line. So making sure that we've got that equipment in the room as well, so we're not egressing and egressing again after that procedure. What things are we doing to prepare the patient here?

BEN DAXON: Well, the things you normally do for somebody that you're about to intubate in the critical care setting still apply here. Bed height, making sure that they're in a good snipping position. All the same rules of good airway management still apply with these patients. We've listed what we think are probably a fair number of those here. The things where this would differ, really in how you pre-oxygenate.

It probably bears repeating, please preoxygenate these people. Again, this is all anecdotal, but there are tons of reports about these people just dropping their stats like a stone the second they're induced. I'm not going to get into all the pathophys that people are speculating about the disease in the lungs. But preoxygenation is paramount.

We are discouraging deep breaths if you are going to preoxygenate. There's a pleurisy with this. A lot of people have discomfort with deep breaths and there's a chance that they'll cough with that. So just kind of normal title breathing. You put three to five minutes. If you've got five minutes, I would definitely err on the side of more. And then if somebody is already on a BiPAP non-invasive of some sort or if they're on high flow, you could continue that.

If they are not and you're going to start to preoxygenate them, you want to think about how you could preoxygenate without increasing your risk of aerosolization. Normally you just put a mask on. You'd preoxygenate and when you push the drugs after they've induced, most people wouldn't give a second thought to giving an extra squeeze or two on the bag. But now we really need to consider that.

So, tight fitting mask. If you would have to give a breath, a two hand seal is what we would recommend. If you're going to do two hands on the mask, that means somebody else has to squeeze the bag. So just think about that ahead of time. That gets into what we were talking about earlier. Do you have two people or three people in the room? It depends on the context. Obviously 100 percent FiO2. One point we do have on here-- if somebody is on high flow, not to crank it up all the way to 60. We're putting a limit of 50 on there. But I think those are probably the more important principles.

ALEX NIVEN: That lower flow is basically recommendation from respiratory therapy just, again, to minimize the risk of aerosol generation. When you talk about that VE position in terms of the mask to try to apply the best contact and minimize any aerosol generation.

BEN SANDEFUR: Can I add on to what Dr. Daxon was saying? One of the things that we ran into is a little bit of confusion about, well if I'm outside of the room coming up with my care plan, talking with my colleague, the respiratory therapist, and the RN about what the intubation plan will be, drawing up the meds, getting the equipment. Who is with the patient, if it's a three person team?

And I think it bears stating that any other people who are in your care team can be with the patient at that time, because if the aerosol generating procedure has not yet begun they don't need to be at the full airborne precaution. So they can be in your standard modified droplet precautions. The patient can still be with their standard flow nasal cannula or their non-rebreather mask. And there can be a care team with the patient while your three person lean team is preparing for the intubation procedure.

ALEX NIVEN: And certainly, I think the assumption in the ICU is that you've got a bedside nurse who's caring for that patient, who's probably going to assume a lot of the role in terms of medications and things along those lines. Tanner, if you can speak up just a little bit with your response. How on earth do you put a viral filter on a bag valve mask?

TANNER HILL: Well, the bag valve mask setup is actually rather simple and easy to set up.

ALEX NIVEN: Says you.

TANNER HILL: Really, with the bag valve mask setup or the green anesthesia bags that we're accustomed to now in hospital setting here in Rochester. It's really the anesthesia mask with the Hudson viral filter attached to that. And then our anesthesia bag attached to the Hudson filter.

ALEX NIVEN: So in between the two.

TANNER HILL: Right. Correct.

ALEX NIVEN: And then we talked a little bit about this last week, but not everybody on the video exchange was potentially here last week. We talk about also deploying viral filters onto the ventilator circuits sort of preemptively, before we start. How does that work?

TANNER HILL: Yeah. On all of our ventilators now, we are filtering both the inspiratory and expiratory lines of circuitry. So that's true for ICU ventilators and for non-ICU ventilators, such as the ED. We're filtering both ends of the circuitry to help minimize any potential aerosol generation that we're going to potentially generate with ventilating these people.

ALEX NIVEN: So we're aggressively preoxygenating these people, encouraging spontaneous breathing so that we're not generating aerosol, trying to wash out all that dead space so that it serves as an oxygen reservoir and extends our time from induction to desaturation. So let's talk a little bit about the approach. We've talked already about the fact that we're encouraging rapid sequence intubation reduction. And what drugs are we talking about here? What are some of the considerations we have to think about? Anyone.

STEVE GLEICH: I think you want-- age and sat are going to work fairly quickly and allow you the least amount of time from when you administer them to when you're attempting the airway. And as such, we've listed out a number of possible induction agents. Those will vary by practice area for sure, but they're fairly standard medications that we use both in the ICU setting and the OR, as well as the ED. The two paralytic options are certainly what we'd consider for a rapid sequence intubation. Succinyl choline and rocuronium are our go-tos there, primarily for their fast onset time.

BEN SANDEFUR: One of the things you'll notice is that the dosage that we have listed on the form here, they're on the higher end of dosages. Succinyl choline, 1.5 mgs per kg is a standard dose. But rocuronium, 1.5 is higher than the typical 1.2 that we would go with and that's on the package insert. And that's with a lot of careful consideration that we added that.

Essentially one of the worst scenarios you could find yourself in with one of these patients is with a partially paralyzed patient-- someone who is not paralyzed enough to open their mouth but yet too paralyzed to breathe. So these are individuals that we are planning to render rapidly paralyzed with induction agent adjacent to that and to essentially not find ourselves in a circumstance where we're going to be waking them up.

So that's why the backup plan is of utmost important if you're not able to achieve first pass success. That has to be well articulated to the team, because this is unlikely the patient would be safe in the event of a first attempt failure to try to wait out or reverse the paralytic agent, because they're going to require mask ventilation. They will be coughing, sputtering, and this is not the patient population we want that in.

ALEX NIVEN: Any other comments people want to make there? The only other thing I'll add is certainly we know that we want these patients to be resuscitated, especially if we're using things like propofol. So fluid loading in that sort of situation still remains a controversial topic. Certainly, we also recognize the potential hemodynamic benefits of some of these agents in terms of things like ketamine, but not relying on those things per se. We noticed a decent amount of folks that got hypotensive in the ketofol trial. So having these suppressors ready and even preemptive administration certainly will help minimize human [INAUDIBLE] ability in these sorts of situations.

STEVE GLEICH: I'll just make one more comment on behalf of pediatric patients here. When we go to do the rapid sequence intubation, our goal, certainly in adults, is to not mask ventilate. What I'll say is that younger children, especially infants, are very, very, very unlikely to tolerate a full apneic time. They will almost certainly desaturate with that. And so one of the differences that we try to highlight on the pediatric version of this intubation checklist is that it's expected and it's OK to mask ventilate children after the induction agent and after the paralytic has been given while waiting for that onset.

We try to recommend a cautious mask ventilation with an excellent seal, very gentle breaths. But in this population, I think it's very, very important to recognize that. The other point I wanted to make about the paralytic is that you'll see the dose of succinyl choline for children's a little bit higher here. That's to account for their increased volume of distribution in the younger children. And then certainly consider atropine with succinyl choline administration, particularly in infants and we put that on here as well.

ALEX NIVEN: So we've done all this stuff. We've already talked about basically picking out our best preferred method with our recommended method here, at least being able to keep our face away from the patient. So the tube goes in too easy. We're done, right? What I want to do is march down the algorithm in terms of what next if the first pass is not successful.

So on our algorithm basically, we have a branch point that talks about bougie and repositioning with a second laryngoscopy attempt versus placing a superglottic airway. So how do we sort through that? And what are the decision points there?

BEN DAXON: Repeating with the conference, that depends on the provider and the patient. If you think, well, I just need to adjust the head a little bit. I'm pretty sure I can get the tube back in. Then the next point would be to go to second laryngoscopy. If you go in and you see absolutely nothing, it was totally unexpected, maybe a superglottic airway pull out and have a chance to kind of collect your thoughts before you think about where you go next.

But either way, that decision should hopefully be made in advance. And just as importantly, the other people in the team know what your thinking was beforehand. So the whole team should be on the same page. So it's not one person in their own head deciding what the next step point needs to be. And I apologize. My mask keeps slipping down. I see comments on the COVID Corner. This is not standard mask covering. I apologize.

BEN SANDEFUR: I think the points that Dr. Daxon just made are absolutely critical here. It doesn't matter which one you choose, as long as you're choosing the one that's right for that patient. And if the team doesn't know what you're going to deploy in the event that you don't achieve first pass success, there's going to be confusion and then it's going to lead to essentially breaks in the circuit. Between whether if it's the bag on the patient's face or whatever it is, you're going to have increased potential aerosol generation.

I think one of the slight differences in COVID era as opposed to usual era is a concept of using the superglottic airway as a ventilatory device. Whereas historically, at least in emergency medicine, we've kind of thought of that as the device we deploy if we don't think we can achieve intubation. So I take my first attempt and I think I can get on a second attempt. I'm almost categorically going to bag them like that patient in between my attempts in standard times. Now we're in COVID times where if the patient is morbidly obese and has his easy top gear, maybe I shouldn't be using a bag mask on that patient at all.

So even if I get in with my first attempted look and I discover, as Ben just said, that just with repositioning the head and maybe going to a slightly lower sized tube or a bougie that I'm going to get it on the second attempt. I might still choose an Air-Q LMA as my ventilation device between those two attempts, because you can place it. You can ventilate the patient, get them preoxygenated again before your second attempt, and then remove it and go for your second attempt. And that's a little bit different than, I think, the usual way that we think about utilization of LMAs in normal practice.

ALEX NIVEN: Yeah, I think it's fair to say that this is still going to be an area that's going to evolve as we gain experience with this. We've already talked about the fact that in the critical care setting, we're predominantly using the Air-Qs here in the emergency department. You guys were thinking more.

BEN SANDEFUR: Air-Q is what we're deploying. We see a lot of Kings that come brought to us by EMS. EMS at Mayo Clinic Ambulance Service, the King airway is their primary backup. In COVID times, they're essentially instructed to have one good first best attempt and if that is not successful to place a King LT superglottic device. And so we're likely to see more King airways during this time frame.

In terms of what you utilize in the actual moment-- if you're the proceduralist, the choice is yours. I think it gets back to Dr. Daxon's comment. Use what you're comfortable with. But certainly, I think a lot of folks would be more comfortable deploying the standard second generation LMA-- in our case the Air-Q. That I think gives you a lot of potential options after deployment.

ALEX NIVEN: And I think there's a lot of things that we're going to need to sort through. So potential upper airway trauma, placement of an extraglottic airway. As a pulmonologist, I love the bronch, but I'm not sure if I want to go out of my way to do a fiberoptic intubation through an extraglottic airway if I don't have to. At the same time, that's probably the preferred route if you've got somebody with a BMI of 45 in that ZZ top period-- you're dating both of us there.

BEN SANDEFUR: The other thing-- I'm quite dated. The other thing that I think the superglottic offers-- back to a point that Ben made earlier-- is if you're bag ventilating the patient between attempts, the proceduralist has two hands tied up and the respiratory therapist has at least one hand tied up. If you place a superglottic device and have a good seal, you pretty much need one hand to just hold the ventilator circuit to keep it from pulling the superglottic out.

So you now have two, maybe three hands, to be able to set up for your next attempt. Also if you're ventilating well, there's no rush. You could call down your anesthesiology backup. You may say this was a bad first look, I don't think I can get in on second look. I'm not comfortable doing a fiberoptic exchange. I'm going to call Ben Daxon down to assist me with that. So it gives you options that I think the bag rescue does not allow for.

ALEX NIVEN: So I want to leave some time for questions. I'm going to jump through to the last point in the algorithm, which is talking a little bit about surgical airways and the things to think about that. I don't think any of us do high volumes of emergency surgical airways. We've included it on this algorithm, because we're worried about that stuff. Again, I'll open it up to the group-- whoever wants to start in terms of what sort of things to at least think about. I'm going to say that this is probably a training element that we should be thinking about in the simulation environment as well to prepare ourselves for both now and in the future.