Airway Response Team (ART) Fact Sheet

3/22/2020 COVID 19 Airway and Med Emergency Response C. Spofford, MD, PHD

History

The ART team was developed initially to address patients with respiratory compromise on the floors and decrease the number of Code 4s called. With the advent of COVID-19 in our community it was deemed that this team would be best suited to manage COVID-19 patients with respiratory failure or impending respiratory failure in a structured, trained manner to improve patient outcome and decrease staff contamination.

1. The ART is composed of an anesthesia care provider, a respiratory therapist and a nurse
2. The ART members have all undergone training and simulation for management of emergency airway procedures.
3. This process is fluid and is altered based on feedback given from leadership from Infection prevention and daily huddles.

Elements of ART

1. COVID Carts have been assembled in the Anesthesia workroom and are stationed at the OR front desk. They contain basic airway and PPE supplies, the PAPRs, as well as an amber box for disposal of the Glidescope blade for reprocessing. A dedicated Glidescope is kept with the cart.
2. PPE includes N95 or PAPRs, goggles, gown and two pairs of gloves.
3. If intubating in the ICU, we utilize the unit’s CMACs—but we have the dedicated videoscope for redundancy.
4. Prior to the intubation
   1. Quick huddle with the RN and RT after donning PPE and discuss plan, learn their names, checking each other’s PPE.
   2. Designate the team outside the room: anesthesia tech to be in charge of getting airway equipment and another RN or resident to get drugs and other equipment. They need to also be focused and attentive while you are intubating. They must stay at the room to anticipate what you need.
   3. The Ambu bag at the head of the patient must have a viral filter between bag and mask. Set the flow to 10LPM and keep a tight mask seal.
   4. Enter the room with your VL, amber box, ETT with syringe and stylet, doffing checklist and anything else you are likely to use. See the checklist of what to bring in the room.
   5. Medications for induction, intubation and immediate hemodynamic control are brought for intubation.
5. For the induction/intubation
   1. Preoxygenate preferably 5 minutes if possible, RN will push drugs in a rapid sequence manner, have RT hold cricoid pressure in one hand while they hold the circuit in the other (vent on standby—no flow). No mask ventilation.
   2. You will intubate. RN will pull stylet and inflate cuff. RT will put circuit on tube with RN assist (remember your hands are full—one hand hold blade one holds tube).
   3. RN can hold tube while you remove blade, disassemble it from power cord, and place it in the amber box. If the blade was a CMAC it must have a cap placed to prevent damage. Spray the blade and stylet (if used) with the Kleenz spray.
   4. Doff your outer gloves and put the lid on the amber box. Wipe the entire outside of the box off with a purple top wipe and hand it to the tech outside for a second wipe down.
   5. Get a purple wipe and clean the outside of the VL tower, covering all surfaces. Hand it out to the tech outside for another wipe down.
   6. If you are wearing a PAPR have the RT or RN don clean gloves (or remove their outer glove) and using a purple wipe, clean off the entire PAPR surface while you are wearing it and it is on.
   7. Doff as usual, following the checklist to avoid error and to keep up with any changes— realize there will be changes as things unfold. By following a cognitive aid, you will always have best practice.
   8. In the hallway, wipe down your PAPR again once it is off and put it back in the bin. Make sure your name is on it. If wearing an N95 take it off, inspect it. Let it dry a bit in the “open” position and then store it in the bag taking care to not touch the inside of the mask. Handle it from the edges at all times (clean or not).
   9. Record the procedure in EPIC.
   10. Huddle with the RN and RT in the hallway afterward to debrief and manage concerns.

Special Circumstances: Anticipated Difficult Airway

1. The ART faculty and resident anesthesiologists will bring 4 PAPRs to all airway emergencies. These are assigned for RT, RN, Anesthesiologist and Surgeon. The individual team members can choose to wear N95 set up instead of PAPR. Everyone should be trained on both.
2. The ART faculty, while at bedside, will make an educated decision about whether they think the patient will be a difficult airway.
3. If the patient is likely going to be easy, they will proceed with the team of 3 and do the protocol of intubation we have previously decided on.
4. If the patient’s airway is deemed to be difficult, the anesthesia team will page the trauma surgeon on call to the bedside. Trauma surgery will bring their tracheostomy tray of choice.
5. Once the surgeon arrives, the two physicians will discuss the best approach and gather equipment. They will create a plan and do a huddle with the RN and RT so there is a clear plan.
6. Most often, the patient’s neck will be prepped and then will be induced. Discussion should occur to plan for an awake tracheostomy vs. an attempt while the patient is anesthetized. And the their plan should follow from that.
7. If the surgical airway were to also fail, you can choose to try and revert to spontaneous ventilation. You can place an LMA hooked to your filter and give gentle ventilation or apneic oxygenation. Consider resource allocation, exposure of the team, and chance of quality of life of the patient as you make these critical decisions together.

Special Circumstances: Unanticipated Difficult Airway

1. If the anesthesiologist has an unanticipated difficult airway, the trauma surgeon will be called emergently to the bedside.
2. The anesthesiologist will consider doing one or more of the following while they wait:
   1. Use a bougie to facilitate videolaryngoscope intubation
   2. Consider Reversing the rocuronium with sugammadex and achieve spontaneous respiration again
   3. Follow the difficult airway algorithm and place LMA attaching a HME anti-viral filter to the Ambu bag and ventilate the patient with small tidal volumes while closing the lips and nose to minimize aerosolization of secretions from leaky LMA. This may also temporize the situation while a surgical airway can be secured.
   4. Place bag-valve mask and provide apneic oxygenation, remembering to give slight squeeze of Ambu bag to open valve (patient is likely not strong enough to create negative pressure inspiratory force to open that valve).