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

Airway Management in Specific Scenarios

Awake Intubation

Awake intubation techniques carry a high risk for aerosolization and should be avoided except for specific situations such as a neck abscess compromising the airway. Antisialagogue and anxiolytic/sedative (eg, dexmedetomidine) administration may help reduce restlessness and droplet generation. Airway topicalization using nebulizers or aerosol-generating atomizers such as the DeVilbiss is not recommended.[45] Mucosal atomizers should be used instead.[45] Local anesthetic impregnated swabs and cotton pledges and nerve blocks may be preferable when used by experienced operators.[45] Single-use fiberoptic bronchoscopes with a separate screen also help reduce contamination.[45] Application of an endoscopy facemask can reduce the exposure of the surrounding to the patient.[46] Use of a smaller size ETT might reduce arytenoid impingement and subsequent coughing.[45] VL-assisted awake intubation can also be considered if appropriate.[45] If awake intubation fails, an awake tracheostomy under local anesthetic may be the only option taking into account the risk of aerosolization.[45]


Tay et al[47] have recently reviewed perioperative considerations of tracheostomy during the COVID-19 outbreak. Drawing on the experience gained during the 2003 SARS outbreak (23 procedures of open tracheostomies) combined with their own understanding, the authors describe certain considerations when planning for an open tracheostomy.[47] First, enhanced PPE measures ranging from face shields over N95 masks to powered air-purifying respirators (PAPRs) were used in those procedures across 5 institutions and all members of the surgical team remained free of infection. Second, the location of the procedure should be carefully evaluated. During the SARS outbreak, most open tracheostomies were performed at the bedside in negative pressure rooms in intensive care units (ICU). This avoided unnecessary transport and the associated risk of ventilatory circuit disconnections. Early clinical judgment in identifying patients at risk and placing them in rooms that are tailor-made or modified to handle aerosol-generating procedures can minimize unnecessary transfers within the ICU. If the procedure needs to be performed in the operating room, it should be done in a dedicated negative pressure theatre suite, if available. Third, aerosol exposure should be minimized by ensuring adequate paralysis, ceasing mechanical ventilation before entering the trachea and limiting the use of suctioning during the procedure. A closed in-line suction unit is recommended. Finally, it is the authors' opinion is that percutaneous tracheostomy involves more extensive airway manipulation, thereby increasing infectious risk, and thus open tracheostomy that allows for faster entrance into the trachea is the preferred technique.