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

Personal Protective Equipment, Airway Equipment, and Preintubation Oxygen Therapy

Personal protective equipment (PPE) is a significant component in minimizing the risk of transmission to health care workers (Figure 2). Based on best practice guidelines and advice from local infectious disease experts, health departments should adopt appropriate PPE (Figure 3) and regularly train staff in donning and doffing practice drills and enforce regular monitoring of stock levels. Disposable equipment is preferred to reusable equipment, subject to availability. The regular airway cart based on the local practices should be kept clean outside the operating theatre, and a separate dedicated COVID-airway cart should be organized.[13] In addition to airway equipment, there should be close access emergency drugs and devices in a clean area outside the intubating room. Readers are referred to recent guidelines[13,18] in relation to preparing the medications and equipment. It is essential to maintain adequate amounts of anesthetic drugs and airway equipment. Critical supply shortages of PPE, medications, and other equipment have been reported across many US hospitals during this outbreak.[19] Organizations such as the Centers for Disease Control and Prevention, American Society of Health-System Pharmacists, The Australian Therapeutic Goods Administration, and various other sources have proposed numerous contingency plans.[17,20–26] Some of the key measures are outlined in Table 2.

Figure 2.

Components of standard airborne precaution personal protective equipment. Modified from Centers for Disease Control and Prevention.17

Figure 3.

PPE guidelines for anesthesiologists. AGP indicates aerosol-generating procedure; BiPAP, bilevel positive airway pressure; COVID-19, coronavirus disease 2019; CPAP, continuous positive airway pressure; PPE, personal protective equipment; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; SGA, supraglottic airway.

Following communication of the airway plan to all team members, the number of people in the room during induction should be minimized (Figure 1). The use of cognitive aids aiming to reiterate rescue plans and an intubation checklist may be useful in minimizing hazards associated with airway management under stressful conditions. It is recommended to have a "runner" in the anteroom. This allows any additional equipment to be passed in, and in addition, the runner can act as a PPE checker. An experienced team and clear "closed loop" communication will reduce the time spent in the contaminated environment. The goals of airway intervention are ensuring patient safety, reducing the spread of the infection, and limiting staff exposure.

Oxygen Therapy Safety Considerations

High-flow nasal cannula (HFNC) therapy has been under immense scrutiny ever since the outbreak, in view of the concerns regarding aerosolization of viral particles. Governing bodies and consensus guidelines differ in their position on using high-flow nasal oxygenation (HFNO) during the time of intubation.[18,27] Recent editorials and other sources have analyzed the available data on bioaerosol generation and dispersion.[28,29] A similar risk profile was noted between standard oxygen masks and HFNO.[29] Based on this, it has been suggested that HFNC prongs when applied with a superimposed surgical mask may be a reasonable practice in hypoxemic patients where potential intubation may be avoided.[29] Reports from Wuhan, China, describe that HFNC-assisted fiberoptic intubation in paralyzed critically ill patients resulted in shorter intubation times and a better oxygenation profile compared to oxygenation through a standard facemask.[30] Clinicians should adhere to locally agreed principles based on the transmission risk in the community in using a HFNC technique. Consensus guidelines recommend low-flow nasal oxygen therapy (flows <5 L/min) in patients at risk of hypoxia during tracheal intubation, in an attempt to extend the apnea time.[18] If a nonrebreather mask is used, flow rates should be limited to 15 L·minute−1 and a viral filter should be attached directly to the mask.[31] Special facemasks with in-built viral filters such as the Tavish (RESPAN, Ontario, Canada) facemask and the HiOx (Novus Medical, Ontario, Canada) nonrebreather mask are better options if available. A surgical facemask should be applied over any oxygen delivery device.