ABC | Volume 114, Nº6, June 2020

Statement Guimarães et al. Position Statement: Cardiopulmonary Resuscitation of Patients with Confirmed or Suspected COVID-19 – 2020 Arq Bras Cardiol. 2020; 114(6):1078-1087 recommended that orotracheal intubation always be performed by the most experienced operator present; •Videolaryngoscopywith a blade capable of providing awide- angle view should be the first-line method of choice for quick, safe, and definitive airway management, ideally on first attempt, and always performed by themost experienced physician. In the event of intubation failure, the assistance of a second operator must be requested immediately. Videolaryngoscopy should again be prioritized for the second attempt; 16,20,21 • For children, videolaryngoscopy with a blade suitable for the size of the patient is recommended; there is no particular need for a wider view angle; 20 • If intubation fails again or is deemed impossible, an extraglottic device (laryngeal tube or laryngeal mask) should be placed. This will allow closed-circuit mechanical ventilation and capnography until conditions are present for establishment of a definitive (surgical) airway via tracheostomy or cricothyrotomy. 20,22 In children, a laryngeal mask suitable for the patient’s weight and size is the extraglottic device of choice. 23 In Brazil, placement of extraglottic airway devices is within the scope of practice of both physicians and nurses, and can thus be an alternative for airway management in prehospital intermediate life support or limited advanced life support, as well as in nurse-led codes. 1,2 Nevertheless, endotracheal intubation is still recommended whenever possible, largely with the aim of reducing aerosol generation; •Whenmore than one extraglottic device is available, priority should be given whenever possible to that providing the best airway seal and the possibility of sequential placement of an orotracheal tube through the device lumen (Fastrach™ or other intubating laryngeal mask airway); • Even after a patient has been intubated or has an extraglottic device in place, occlusion and sealing of the oral cavity is still important to reduce aerosolization; this can be done with towels, gauze packs, or a standard surgical mask; • When cardiac arrest occurs in a patient already on mechanical ventilation, the patient should be connected to the ventilator through a closed ventilation circuit and the ventilator parameters set as follows (Chart 1): ○ Mode: volume assist-control ventilation (AC or ACV). Tidal volume (V T ): 6 mL/kg predicted body weight. ○ Fraction of inspired oxygen (FiO 2 ): 100%. ○ Respiratory rate (RR): approximately 10 breaths per minute; inspiratory time (Ti): 1 second. ○ Flow triggering: off; if triggering cannot be disabled, switch to pressure-triggering mode and adjust the triggering pressure to the least sensitive (i.e., lowest) possible threshold; this ranges from -15 to -20 depending on ventilator model. Figure1– Bag-valve-maskdevicefittedwithHEPAfilter.Source:Personalcollection. Figure 2 – Manikin simulation of an intubated patient being ventilated with a bag- valve-mask device fitted with a HEPA filter. Note surgical mask covering the nose and oral cavity. Source: Personal collection. Figure 3 – Manikin simulation of a patient with an extraglottic airway device being ventilated. Note HEPA filter and surgical mask covering the nose and oral cavity. Source: Personal collection. 1082