ventilator setup and management for suspected and

Guideline No:

Guideline:

Disclaimer This document is available on-line as a stimulus for interchange of knowledge and ideas in the field of Neonatal and

Paediatric Retrieval. It is provided "as-is" and without support or warranty of any kind. Many of our guidelines may not be appropriate for use in retrieval settings other than NETS NSW, especially in non-Australian environments.

This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be

factors which cannot be covered by a single set of guidelines. This document does not replace the need for the

application of clinical judgement to each individual presentation.

Approved by: SCHN Policy, Procedure and Guideline

Committee

Date Effective: Review Period: 3 years

Team Leader: Area/Dept: NETS

Date of Publishing: 21 August 2020 9:43 PM Date of Printing: of 15

G:\Committees\Guideline Committee\COVID19\Current COVID guidelines\COVID-19 Ventilator Setup version 2

21.08.2020.docx

This Guideline may be varied, withdrawn or replaced at any time.

VENTILATOR SETUP AND MANAGEMENT FOR

SUSPECTED AND CONFIRMED COVID-19

PATIENTS

PRACTICE GUIDELINE ©

DOCUMENT SUMMARY/KEY POINTS

In suspected or confirmed COVID- 19 patients:

Use of a closed suction system must be used for all intubated patients

Bacterial/Viral filters must be added to all ventilation circuits except in the first 14 days of

life in neonates born to women with COVID-19 or risk factors for COVID-19

Bacterial/Viral filters must be attached to emergency bag-mask equipment except in

neonates ≤ 14 days of life.

PPE for airborne precautions must be worn during aerosol generating procedures

(AGPs)

Avoid disconnection of the ventilation circuit once connected to the patient Only in an emergency should manual ventilation be performed Only in an emergency should open suction be performed

Avoid aerosol generating procedures, i.e. ventilator circuit disconnection, open

suctioning, nebulization (unless it is nebulization via the Aerogen)

Includes process for safe sequence of surfactant administration if required

CHANGE SUMMARY

Guideline No:

Guideline:

Disclaimer This document is available on-line as a stimulus for interchange of knowledge and ideas in the field of Neonatal and

Paediatric Retrieval. It is provided "as-is" and without support or warranty of any kind. Many of our guidelines may not be appropriate for use in retrieval settings other than NETS NSW, especially in non-Australian environments.

This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be

factors which cannot be covered by a single set of guidelines. This document does not replace the need for the

application of clinical judgement to each individual presentation.

Approved by: SCHN Policy, Procedure and Guideline

Committee

Date Effective: Review Period: 3 years

Team Leader: Area/Dept: NETS



21.08.2020.docx


This is a new guideline

READ ACKNOWLEDGEMENT

NETS clinical staff are to read and acknowledge they understand the contents of this

guideline.

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Preparation for ventilation circuit setup

Appropriate PPE

COVID-19 pack (Neonatal or Paediatric) in retrieval bag (see attachment 1 for content list)

Only take the items you require from the retrieval bag to the patient area

To minimise contamination of the COVID-19 pack and retrieval bags, avoid taking into the patient care area. If this is unavoidable, keep bags at least 2 meters away from the patient

Only a clean person to access retrieval bags

Do not discard unused items from COVID-19 pack – return into retrieval bag

Equipment Required

1. Appropriate sized inline suction system

Ambu Cath closed system suction catheter (with elbow – sizes ≥FG7) - see picture 1

OR

Ambu Cath closed system suction catheter (without elbow – FG6) and Air Life Neo-Verso Airways Access Adaptor® (Y-adapter) - see picture 2

Picture 1

Picture 2

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OR

Halyard closed suction system (with elbow – all sizes) – see picture 3

2. 2x Bact-Trap™ filter (wet circuits) OR 1x green HME (dry circuit). No

Bact-Trap™ filter at ETT end of circuit in neonates ≤ 14 days of life

3. 1x Bact-Trap™ or HME filter for bagging circuit except in neonates

aged ≤ 14 days

4. ETCO2 sampling line

5. Appropriate ventilation circuit

6. ETT clamp

Setting Up

Prepare ventilator and circuit before entering patient area:

Set up ventilator and perform leak test

Set ventilation parameters and confirm with test lung - anticipate

higher pressures, longer inspiratory times and appropriate breath rate

for I:E ratio, to account for large dead space

Activate standby/turn off ventilator and cover inline suction with clean

glove or plastic bag until ready to attach to patient

Leave test lung in the retrieval bag to remain clean

Ensure ETCO2 monitor is turned on prior to intubation

Picture 3

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Crossvent 2i setup:

Attach one Bact-Trap™ filter to exhalation

valve

Connect ETCO2 to ventilation circuit

Connect Bact-Trap™ filter to ETCO2

connector

Do not use Bact-trap filter at the ETT

connector in the first 14 days of life in

neonates born to women with COVID-19 or

risk factors for COVID-19

Do not use green HME filter in wet circuit

Connect chosen inline suction system to Bact-Trap™ filter

NOTE:

- If using the Ambu Cath FG6 inline suction catheter a Y-adapter is

required. The inline suction catheter will connect to the Y-adapter

at the port which has a lid

- If using the Halyard brand

FG6 inline suction catheter,

the elbow connector

attaches straight onto ETT

- Do not use a pneumotach

with Crossvent2i – the Bact-

Trap™ filter has a 31mL

dead space; a pneumotach

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will increase dead space further

- Without the pneumotach, only CMV mode can be used with the

Crossvent 2i ventilator

Hamilton-T1 ventilator setup:

Attach one Bact-Trap™ filter to exhalation housing

Attach a bacterial/viral filter to pre-humidification tubing, as per usual practice (use the clear filter provided with adult circuit or Bact-Trap™ filter or HME filter)

Connect ETCO2 to ventilation

circuit/flow sensor

Connect Bact-Trap™ filter to ETCO2

connector (Do not use green HME

filter in wet circuit)

Connect chosen inline suction system to Bact-Trap™ filter

Inline Suction set up with Y-adaptor Inline Suction set up with elbow

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Oxylog ventilator setup:

The Oxylog 3000+ ventilator has a single limb dry circuit

Connect ETCO2 to ventilation circuit

Attach appropriate sized green viral/bacterial HME to ETCO2

connector

NOTE:

- Cannot use a Bact-Trap™ filter

as it is not a HME and does not

provide any passive

humidification

- Only one viral filter that also

provides passive humidification

is required for the Oxylog

ventilator. If you need to

remove/replace an

additional/incorrect filter, clamp

ETT before breaking the closed

circuit

Attach appropriate size Inline

suction system to HME

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Connecting to patient

1. The ideal situation is a successful first attempt intubation, connecting

straight onto the ventilator circuit without giving manual breaths

If attaching ventilator setup immediately after intubation, ETT

clamping is not required

Following successful intubation attach the ventilator circuit setup

to the patient ETT and start mechanical ventilation

Confirm ETT position looking for chest rise, ETCO2 waveform,

misting of the ETT and auscultation

2. If the patient has needed emergency bagging immediately after

intubation, the following sequence needs to be performed to connect

onto the NETS ventilator circuit:

Cease giving breaths and give PEEP only

Clamp ETT to maintain PEEP and minimise exhaled volumes

Turn off gas flow to the bagging circuit, this may be achieved

simultaneously with ETT clamping

Disconnect the bagging circuit and filter

Connect ventilator circuit setup to ETT from the inline suction

Unclamp ETT

Start ventilator

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Managing ventilation disconnections

Transition to receiving hospital ventilator:

For a successful and risk-free transition, the NETS team should always

be leading the discussion for disconnection and connection onto the

receiving ventilator

Complete clinical handover to the receiving team

Transfer patient to receiving bed as per NETS General Retrieval

Guidelines

Ensure receiving ventilator circuit is ready:

- The receiving team may be happy to keep the NETS inline

suction and filter in place, OR

- The receiving team may want to connect their own inline

suction and filter

NETS team to perform the disconnection and connection sequence:

1. Turn off NETS ventilator at the end of expiration

2. Clamp ETT

3. Disconnect NETS circuit from the pre-determined connection point

- Either at the ETT connector, thus removing NETS inline

suction and filter, OR

- At the filter, thus leaving the inline suction and filter still

connected to the patient ETT

4. Connect the receiving ventilator circuit setup

5. Unclamp ETT

6. Start receiving ventilator

Emergency bagging during mechanical ventilation:

Manual ventilation should be avoided wherever possible. However, if

emergency bagging is required:

1. Activate ventilator stand-by at the end of expiration to stop gas flow

2. Clamp ETT

3. Disconnect only the ventilator circuit from the ETCO2 connector,

leaving the inline suction, filter and ETCO2 attached to patient ETT

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4. Attach only the bagging system

onto ETCO2 connector (there

should be only 1 filter in the

system)

5. Unclamp ETT

6. Turn on gas flow to bagging

system

When ready to recommence mechanical ventilation: 1. Cease giving breaths and give PEEP only

2. Clamp ETT to maintain PEEP and minimise exhaled volumes

3. Turn off gas flow to the bagging system, this may be achieved


4. Disconnect the bagging circuit from the ETCO2 connector

5. Connect ventilator circuit to ETCO2 connector

6. Unclamp ETT

7. Restart ventilator

Emergency bag-mask ventilation:

If emergency bag-mask ventilation is required,

there should always be a viral/bacterial filter

attached between the bagging system and mask

except in the first 14 days of life in a neonate.

In infants, use HME filters with the smallest

possible dead space at the bagging system

interface. Small HME filters are included in the

neonatal COVID-19 pack

A 2-hand technique should be used to ensure a

tight seal over the patient nose and mouth, with

another team member giving manual breaths

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Surfactant Administration

Prepare surfactant as per NETS Surfactant Administration policy

Surfactant administration needs to occur with minimal risk of AGPs –

avoid manual ventilation if possible

Remember to treat the baby normally however if truly suspicious of, or

with confirmed vertical transmission of COVID-19, have a low

threshold to add muscle relaxation to prevent the baby coughing and

therefore aerosolizing when surfactant is administered

Place a clear sterile drape over the baby head for secretion control

during administration

Use any one of the situations below as guidance:

Administration immediately after intubation:

- If the patient is stable enough, the surfactant may be given as one

aliquot immediately after intubation prior to connecting to the

ventilation circuit and commencing initial mechanical ventilation

- Consider higher pressures and longer iTime may be required

initially given the extra dead space with inline suctioning.

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Administration during mechanical ventilation:

- Ensure adequate mechanical ventilation

- Ensure emergency bagging equipment is available

- When ready, follow the sequence as many times as needed until

the full dose of surfactant is given:

1. Turn off ventilator

2. Clamp ETT

3. Disconnect circuit from

the in-line suction end,

leaving only the ETT

connector

4. Unclamp ETT

5. Feed the surfactant tube

into ETT, administer

surfactant

6. Reconnect circuit to ETT

7. Turn on mechanical ventilation

Post Administration desaturation:

- If the baby desaturates post administration increase the PIP and

the rate briefly to recover the physiology

- If increasing the mechanical ventilation has not been successful

and manual ventilation seems the only option following surfactant

administration and is on the ventilator, follow the sequence as per

disconnection from the ventilator:

1. Turn off ventilator at the end of expiration

2. Clamp ETT

3. Disconnect only the ventilator circuit from the

ETCO2 connector, leaving the inline suction

and ETCO2 attached to patient ETT

4. Attach only the bagging system onto ETCO2

connector

5. Unclamp ETT

6. Turn on gas flow to bagging system

When ready to recommence mechanical ventilation:

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1. Cease giving breaths and give PEEP only

2. Clamp ETT to maintain PEEP and minimise exhaled volumes

3. Turn off gas flow to the bagging system, this may be achieved


4. Disconnect the bagging circuit from the ETCO2 connector

5. Connect ventilator circuit to ETCO2 connector

6. Unclamp ETT

7. Restart ventilator

Trouble shooting

ETCO2 readings will be unreliable due to the large dead space in the ventilation circuit setup – use for ETT placement and trends in increasing or decreasing CO2

Anticipate the need for higher pressures, longer inspiratory times and appropriate I:E ratios to overcome dead space

Assess patient for ventilator asynchrony – have low tolerance for appropriate levels of sedation and muscle relaxation

Change Bact-Trap™/HME if excessively wet (viral filtration is not guaranteed when wet)

When changing between ventilator and manual circuits, there should only be one viral/bacterial filter at the patient interface – more than one filter will increase the dead space significantly. The exception to this is with the neonate aged 14 days and under.

References

1. Agency for Clinical Innovation (2020). Aerosol generating respiratory therapies.

2. AMPA (2020). AMPA Position Statement. https://www.ampa.org/

3. Australian and New Zealand Intensive Care Society (2020). ANZICS COVID-19 Guidelines. Version 1. Melbourne: ANZICS https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf

4. Australian Government Department of Health (2020).Information for aeromedical retrieval of patients with COVID-19 https://www.health.gov.au/sites/default/files/documents/2020/03/coronavirus-covid-19-information-for-aeromedical-retrieval-of-patients.pdf

5. Brewster D, Chrimes N, Do T, Fraser K, Groombridge C, Higgs A, Humar M, Leeuwenburg T, McGloughlin S, Newman F, Nickson C, Rehak A, Vokes D and Gatward J (2020). Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. The Medical Journal of Australia.

https://www.ampa.org/

https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf

https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf

https://www.health.gov.au/sites/default/files/documents/2020/03/coronavirus-covid-19-information-for-aeromedical-retrieval-of-patients.pdf

https://www.health.gov.au/sites/default/files/documents/2020/03/coronavirus-covid-19-information-for-aeromedical-retrieval-of-patients.pdf

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https://www.mja.com.au/journal/2020/212/10/consensus-statement-safe-airway-society-principles-airway-management-and

6. Clinical excellence commission (2020). Infection prevention and control practise handbook. http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0010/383239/IPC-Practice-Handbook-2020.PDF

7. Clinical excellence commissions (2020). Infection Prevention and Control Novel Coronavirus 2019 (2019-nCoV) – Hospital setting https://intranet.schn.health.nsw.gov.au/files/attachments/7714/infection-control-ncov-2019-hospital-setting-v2.pdf

8. Medtronic (2019). Effective humidification. Effective protection. DAR™ filter HMEs. https://www.medtronic.com/content/dam/covidien/library/us/en/product/ventilator-filters/dar-breathing-filter-hme-sellsheet.pdf

9. NSW Ambulance (2020). Clinical Practice standard – Aeromedical operations AO.CLI.23- Novel Coronaviruseshttps://nswhems.files.wordpress.com/2020/03/ao.cli_.23-novel-coronaviruses-approved-by-aed-11-03-2020.pdf

10. SCHN (2015). Airway suction in PICU-CHW Practice Guideline. http://webapps.schn.health.nsw.gov.au/epolicy/policy/1934/download

11. SCHN (2019). Respiratory support in neonates – GCNC – CHW. Practice Guideline http://webapps.schn.health.nsw.gov.au/epolicy/policy/4507/download

12. Matava CT et al (2020) Pediatric airway management in COVID-19 patients- Consensus guidelines from the Society for Pediatric Anaesthesia’s Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anaesthesia Society. Anesth Analg DOI:10.1213/ANE.00000000000004872 Accessed via https://www.schn.health.nsw.gov.au/files/attachments/matava-pediatric_airway_managemen-anesth_analg.pdf

13. NSW Government. Clinical Excellence Commission (25Jun2020). Safety Notice 006/20. Use of Viral filters for respiratory care in neonates.

14. Shalish W, Lakshminrusimha S et al. (2 May 2020). COVID-19 and neonatal respiratory care: current evidence and practical approach. Am J Perinatol. doi:10.1055/s-0040-1710522.

15. Terheggen U, Heiring C, Kjellberg M, et al. European consensus recommendations for neonatal and paediatric retrievals of positive or suspected COVID-19 patients [published online ahead of print, 2020 Jul 7]. Pediatr Res. 2020;10.1038/s41390-020-1050-z. doi:10.1038/s41390-020-1050-z

Attachment:

http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0010/383239/IPC-Practice-Handbook-2020.PDF

http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0010/383239/IPC-Practice-Handbook-2020.PDF

https://intranet.schn.health.nsw.gov.au/files/attachments/7714/infection-control-ncov-2019-hospital-setting-v2.pdf

https://intranet.schn.health.nsw.gov.au/files/attachments/7714/infection-control-ncov-2019-hospital-setting-v2.pdf

https://www.medtronic.com/content/dam/covidien/library/us/en/product/ventilator-filters/dar-breathing-filter-hme-sellsheet.pdf

https://www.medtronic.com/content/dam/covidien/library/us/en/product/ventilator-filters/dar-breathing-filter-hme-sellsheet.pdf

http://webapps.schn.health.nsw.gov.au/epolicy/policy/1934/download

http://webapps.schn.health.nsw.gov.au/epolicy/policy/4507/download

https://www.schn.health.nsw.gov.au/files/attachments/matava-pediatric_airway_managemen-anesth_analg.pdf

https://www.schn.health.nsw.gov.au/files/attachments/matava-pediatric_airway_managemen-anesth_analg.pdf

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The use of this document outside Sydney Children's Hospitals Network (SCHN), or its reproduction in whole or in part, is subject to acknowledgement that it is the property of SCHN. SCHN has done everything practicable to make this document accurate, up-to-date and in accordance with accepted legislation and standards at the date of publication. SCHN is not responsible for consequences arising from the use of this document outside SCHN. A current version of this document is only available electronically from the Hospitals. If this document is printed, it is only valid to the date of printing.

ventilator setup and management for suspected and

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