Considerations for Extubation of COVID-19 Patients (positive or suspected)

1. Intubation has been recognized as a time when aerosolization of respiratory secretions increases risk of transmission of SARS-CoV-2.
2. Extubation may represent an equally significant risk, due to coughing and during removal of endotracheal tubes and supraglottic airways.
3. The suggestions below may merit consideration not only for known infected patients, but also those with exposure to infected patients.
4. In order to minimize aerosolization and the risk of transmission during extubation, the following suggestions may be considered:

• All non-essential staff should exit OR prior to extubation or stand > 6 feet away from the patient’s head.
• Use of medications at emergence that may reduce coughing; these can include dexmedetomidine, fentanyl, remifentanil, lidocaine intracuff, lidocaine IV.¹
• Consider not pressurizing airway during extubation, reduce gas flow to minimal or low flows immediately prior to ETT removal.
• Attempt to extubate at end-expiration.
• Consider deep extubation for select patients.²
• Be aware that oropharyngeal suction may generate aerosols.
• Balance above considerations against risk of aspiration or airway problems post-extubation
• Be aware that suctioning within the endotracheal tube may generate coughing at a time when the ETT is open and secretions can enter OR. Consider using a closed suction system like the ones used in the ICU.
• Consider placing a plastic sheet, towel, or other barrier over patient’s face at time of extubation to block secretions from entering OR.³
• Consider using plastic bag over ETT and face at time of extubation, so ETT goes into and remains in plastic bag, which would catch any coughed secretions, and provides packaging to contain ETT for disposal in red trash.
• Place a second filter on mask and position mask so it covers the mouth and the ETT exits under the mask; extubate while maintaining mask seal; once extubated, connect circuit to filter on mask.
• As soon as it is established that patient is ventilating, place yellow mask on patient and supply oxygen by face mask, as usual.⁴

¹ Tung A, Fergusson NA, Ng N, Hu V, Dormuth C, Griesdale DEG.  Medications to reduce emergence coughing after general anaesthesia with tracheal intubation: a systematic review and network meta-analysis.  BJA 2020; 124:480-495.

² Contraindications to deep extubation include aspiration risk, difficult mask ventilation, difficult airway (either due to patient conditions or type of surgery), lack of access to airway.  Patients should have full reversal of neuromuscular blockade and exhibit good spontaneous respiration.

³ https://twitter.com/innov8doc/status/1240455223929458696?s=21 (video showing effectiveness of cover over face).

⁴ https://twitter.com/innov8doc/status/1241332862235873285?s=21 (video showing dispersal if only a face mask is used, without yellow or surgical mask on patient).