There is increasing evidence that Awake Self-Proning of our Covid-19 patients can improve oxygenation. Proning the patient can has several effects which can dramatically improve their SaO2

• Improves Ventilation to back of the lung (the back of the lung contains more alveoli than the anterior lung)
• Improves Perfusion – as blood supply to the back of the lung is always better than the front
• Improves Clearance of secretions

• NIV/CPAP  is an Aerosol Generating Proceedure (AGP)
  • Staff must wear full APG PPE
  • In Side room with a door
  • Door Marked with APG sign – HERE
• CPAP/EPAP levels of 8-15cmH₂O setup video and picture

• BTS has released the guidance – HERE 
  • Masks
    • Well-fitting oronasal facemasks, masks over the total face, or helmets should produce least droplet dissemination.
    • Vented masks could worsen contamination of the environment
    • Any patient on acute NIV should be managed with a non-vented mask and an exhalation port in the circuit.
    • Ensure that the ventilator mode employed supports the use of non-vented masks and exhalation ports.
    • Sequence of actions: NIV mask on >ventilator on; ventilator off > NIV mask off.
  • Filters
    • A viral/bacterial filter should be placed in the circuit between the mask and the exhalation port (Figure below).
    • This viral/bacterial filter can replace any filter at the machine end of the circuit.
    • Viral/bacterial filters should ideally be changed every 24 hours or sooner. (There is a risk that they will become wet due to exhaled gas and that this may increase resistance to flow.)
    • An external humidifier must not be used.
    • Blocked filters can be mistaken for clinical deterioration; this issue is remedied by changing filters.
  • Oxygen – entrained at patients end (on mask

Destinations

• • • Failing on NIV/CPAP – Consider either escalation to intubation OR palliation
    • Maintaining Oxygenation – At CRH negative pressure room, at HRI side room acute floor

If Treating Moderate/Severe Pneumonia with antibiotic please ensure – Sputum/Urine/Blood samples ordered

Avoid NSAIDS

Tamiflu – Only if confirmed influenza

Deteriorating Patients

• Early senior decision making around DNACPR, is vital for both staff, patients, and families.
• Document decsion making and communications clearly
• There will be regular updates in “handover” about ICU admission criteria – as these may change over time

CPR (Aerosol Generation Proceedure)

1. Recognise cardiac arrest.
   • Look for the absence of signs of life and normal breathing.
   • Feel for a carotid pulse if trained to do so.
   • Do not listen or feel for breathing
   • If there are any doubts – start chest compressions until help arrives.
   • When calling for help/2222, state the risk of COVID 19.
2. Minimum PPE; gown, eye protection, gloves and FFP3 mask/Hood before starting chest compressions
   • No chest compressions or airway procedures such as those detailed below should be undertaken without full AGP PPE.
3. Start compression-only CPR and monitor the patient’s cardiac arrest rhythm as soon as possible.
   • Avoid mouth-to-mouth ventilation and the use of a pocket mask.
   • Place oxygen face mask on the patient’s face during chest compressions (may limit aerosol spread).
   • Restrict the number of staff in the room (if a single room). Allocate a gatekeeper to do this.
4. Defibrillate shockable rhythms rapidly 
5. LMA/ETT insertion –  must be carried out by experienced individuals.
6. Identify and treat any reversible causes 
7. Post-CPR
   • Dispose of, or clean, all equipment used during CPR
   • Remove PPE safely to avoid self-contamination
   • Hand hygiene has an important role in decreasing transmission.
   • Post resuscitation debrief is important and should be planned.

FULL Resus Council – GUIDE HERE

Scenario 1 – Staff member Symptomatic

Scenario 2 – Staff member asymptomatic, with a positive contact (inc. within household)

Full guide – HERE