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

Environment for Airway Interventions

Airway management and any subsequent surgical or procedural interventions should preferably be conducted in dedicated negative pressure rooms labeled as "airborne infection isolation rooms" (AIIR) with a minimum of 12 air changes per hour.[12] To prevent infection to those outside the room, air is filtered with a high-efficiency particulate air (HEPA) filter and evacuated from these rooms to the external atmosphere.[2] The doors should remain closed during the intervention, to optimize the frequency of these air changes. If negative pressure rooms are not available, consultation with the bioengineering departments within an institution should be sought to optimize existing workflows.[13] Alternate options to negative pressure room are depicted in Figure 1. Aerosol clearing times after any aerosol-generating medical procedure should be established based on the ventilation flows (air changes per hour)[14] (Table 1). A 30-minute waiting period is recommended for rooms with 12 air changes per hour after intubation and extubation.

Figure 1.

Layout of the airway intervention suite. COVID indicates coronavirus disease; HEPA, high-efficiency particulate air. Modified with permission from Brewster et al.13

Transfer protocols should be developed and rehearsed with the goal of minimizing interaction with other patients and staff.[15] The principles of intrahospital transfer have been reviewed recently by Coccolini et al.[16] A decision to transport a stable patient between 2 areas (before airway management) should only be conducted if the new area has better equipment, more experienced staff, and a controlled environment or if transferring to the operating/procedure room.[13] A separate anteroom should be established for keeping the essential procedural kits, equipment, and drugs with a set of runners remaining in the anteroom (Figure 1). Alternatively, if a separate anteroom is not available, an adjacent operating room could be used instead.[15] Local infectious disease experts should be involved in designing dedicated interventional areas, inclusion of protective equipment, and intrahospital patient flow.