Airway Management in the Operating Room and Interventional Suites in Known or Suspected COVID-19 Adult Patients

A Practical Review

Venkatesan Thiruvenkatarajan, MD, DA, DNB, FANZCA; David T. Wong, MD; Harikrishnan Kothandan, DNB, DA, FANZCA, MClinUS, FAMS; Vimal Sekhar, MBBS, MClinSci; Sanjib Das Adhikary, MD; John Currie, MBChB, FFARCSI; Roelof M. Van Wijk, MD, PhD, FANZCA, FFPMANZCA


Anesth Analg. 2020;131(3):677-689. 

In This Article

Abstract and Introduction


Current evidence suggests that coronavirus disease 2019 (COVID-19) spread occurs via respiratory droplets (particles >5 μm) and possibly through aerosol. The rate of transmission remains high during airway management. This was evident during the 2003 severe acute respiratory syndrome epidemic where those who were involved in tracheal intubation had a higher risk of infection than those who were not involved (odds ratio 6.6). We describe specific airway management principles for patients with known or suspected COVID-19 disease for an array of critical care and procedural settings. We conducted a thorough search of the available literature of airway management of COVID-19 across a variety of international settings. In addition, we have analyzed various medical professional body recommendations for common procedural practices such as interventional cardiology, gastroenterology, and pulmonology. A systematic process that aims to protect the operators involved via appropriate personal protective equipment, avoidance of unnecessary patient contact and minimalization of periprocedural aerosol generation are key components to successful airway management. For operating room cases requiring general anesthesia or complex interventional procedures, tracheal intubation should be the preferred option. For interventional procedures, when tracheal intubation is not indicated, cautious conscious sedation appears to be a reasonable approach. Awake intubation should be avoided unless it is absolutely necessary. Extubation is a high-risk procedure for aerosol and droplet spread and needs thorough planning and preparation. As updates and modifications in the management of COVID-19 are still evolving, local guidelines, appraised at regular intervals, are vital in optimizing clinical management.


Suspected or confirmed "coronavirus disease 2019" (COVID-19) positive cases due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) present unique challenges to health care workers as the rate of transmission to health care personnel remains very high. In Italy, among the infected cases, 9% were health care workers.[1] The transmission occurs by means of respiratory droplets (>5 μm) as well as through hand and surface contamination.[2] The viral load in the airway is presumably very high and hence poses significant infective transmission risk during airway management.[3,4] Previous experience during the 2003 SARS-CoV outbreak suggests that the virus could be transmitted during aerosol-generating procedures, most commonly during endotracheal intubation.[5,6] Recent experimental findings suggest a potential aerosol (<5 μm) transmission of SARS-CoV-2.[7] Health care workers involved with tracheal intubation during the 2003 SARS epidemic had a higher risk of contracting the virus (odds ratio 6.6).[8] Notably, most of those health care workers were only wearing a standard surgical facemask during intubation. It is considered that there is no strong link between intubation and transmission risk when appropriate airborne precautions are followed.[9]

SARS-CoV-2 is genetically 85% similar to the previous SARS-CoV. Yet SARS-CoV-2 is a distinctly new coronavirus strain.[10] Although the transmission rate is high, the case fatality rate of COVID-19 (varying across regions) seems to be lower than that of SARS (9.5%).[11] We aim to outline procedure-specific principles of airway management for suspected or proven COVID-19 patients. These suggestions have been derived from recently published literature, recommendations from various international governing organizations and consensus guidelines. As the COVID-19 situation is dynamically changing with time, this review is presented with an understanding that updates and modifications to clinical practice will continue to evolve. Thus, this review should be read in conjunction with updated local guidelines and protocols.