Preliminary oxygenation is obligatory for patients with COVID-19 because of risk of fast decrease in level of saturation of hemoglobin of an arterial blood oxygen. After optimization of position of the patient and correction of hemodynamic disturbances execute preliminary oxygenation with fraction of the inhaled oxygen of 100% within not less than 3 minutes at active breath or eight breaths, each of which is equal to the vital capacity of lungs.
The fast consecutive intubation shown for all cases to minimize apnoea time, can lead to a considerable aerozolization if ventilation of the lungs with use of a respiratory mask is carried out. Therefore such ventilation of the lungs has to be carried out with care and only if there is a decrease in saturation of hemoglobin of an arterial blood oxygen to a critical mark.
If there are no other instructions, Selick's reception should not be used. Thus, primary success of ventilation can be maximized, and optimum ventilation of the lungs (if necessary) is not broken. For prevention of desaturation apnoyny oxygenation with use of low-line nasal oxygenation is recommended during attempts of an intubation of a trachea. As this process is followed by aerosol generation, it is necessary to avoid a high stream of the oxygen given through a nose.
Careful introduction of hypnotic agents is recommended to minimize hemodynamic instability. Introduction a rokuroniya in number of 1.2 mg/kg or succinylcholine — 1 mg/kg which will provide quick start of neuromuscular blockade is also shown and will prevent cough and the related aerozolization. It is recommended to carry out neuromuscular monitoring also.
It is strongly recommended to use at an intubation the video laryngoscope, ideally disposable, but with the separate screen to minimize contact with the patient. In case of failure of an intubation of a trachea it is possible to use carefully manual ventilation of the lungs with the subsequent attempt of an intubation of a trachea (at most twice and taking into account change of situation, the device and the equipment between attempts). If the intubation of a trachea was not successful twice or if the artificial respiratory way is required, is strongly recommended to use epiglottidean devices (laryngeal masks) of the second generation (that device which allows to carry out in the subsequent an intubation through it by means of introduction of the flexible bronchoscope is preferable).
At impossibility to provide passability of respiratory tracts by means of a videolaringoskopiya and installation of an epiglottidean air duct, the surgical or transdermal konikotomiya can be considered). It is very desirable that making decision on a konikotomiya was not postponed until decrease in saturation of hemoglobin of an arterial blood by oxygen below a critical mark. If performance of an intubation in consciousness is shown to the patient, use of intravenous sedation can minimize cough. It is necessary to minimize use of aerosol local anesthesia and to consider the possibility of use for a mucous inhaler, rollers and gauze tampons and also (if the condition of the patient allows) blockade of the nerves innervating the upper airways.
It is necessary to use disposable flexible bronchoscopes to reduce risk of cross infection. It is strongly recommended to use the bronchoscope with the separate screen. It is possible to consider a trachea intubation in consciousness with use of a videolaringoskopiya as it quicker, than a fibreoptic intubation.
Despite aerozolization potentiality, the tracheostomy with local anesthesia has to be considered in case of unsuccessful carrying out an intubation of a trachea and the subsequent awakening of the patient and also when the impossibility of ensuring passability of respiratory tracts with standard methods is obvious. In case of the scenario "it is impossible to intubate, it is impossible to oxygenate" it is necessary to execute an eksrenny konikotomiya.
If the patient with COVID-19 needs the emergency intubation of a trachea, then before ensuring passability of respiratory tracts members of crew have to put on the individual protection equipment (IPE). The sparing ventilation of the lungs with use of a respiratory mask can be required by the hypoxemic patient to give more time to the patient and clinical physicians.
Place virus and bacterial filters of solid particles of air between a front mask or an endotracheal tube and a rebreathing system as soon as the patient is connected to the medical ventilator. It is necessary to avoid depressurization and shutdown of a rebreathing system to prevent spread of a virus.