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 Outside the Operating Room: Interventional Suites

Interventional Pulmonology Procedures

Bronchoscopy is one of the highest risk procedures for aerosol generation.[48] The American Society of Bronchology and interventional Pulmonology (AABIP) has recently issued a statement on bronchoscopy during the COVID-19 outbreak.[49] The AABIP strongly recommends deferring elective interventions in suspected or confirmed cases of COVID-19 until full recovery and viral clearance. The indications for these elective interventions and in the setting of COVID-19 diagnosis are listed in their statement. Urgent bronchoscopy (rigid or flexible) in known or suspected cases is indicated only for life-threatening indications such as massive hemoptysis. Other indications include investigation of severe airway stenosis or identifying the etiology of an endobronchial obstruction.[49] Clearly, the goal is to minimize aerosol generation and droplet dispersion during and after the intervention. The procedure should be performed only in negative pressure rooms. An antisialagogue along with an anxiolytic may be helpful. A major concern with any anesthetic technique is the leak around the oropharyngeal cavity and the need for frequent suctioning. A general endotracheal tube anesthesia (GETA) with a large-sized ETT and neuromuscular blockade may be the best option. Closed in-line suctioning should be used. Both in-line suction and the bronchoscopic port/adapter should be connected at the same time to avoid multiple exposures. Ventilation should be ceased; fresh gas flows should be turned-off and the APL valve should be fully opened during disconnections and suctioning. Higher flow rates to compensate leaks should be avoided if possible. Adequate lubricant applied to the bronchoscope port can often seal a leak. A procedure completed quickly with minimal suctioning attempts will result in less overall risk of leakage. Close communication with the pulmonologist is essential to reduce the contamination risk. For patients not requiring postprocedure ventilatory support, dexmedetomidine, opioids, and intravenous lidocaine are suitable options for cough suppression during extubation.[50,51]

For nonurgent procedures in unsuspected patients, the prevalence rate of COVID-19 infections should be considered in deciding the best management strategies.[49] In regions with a high prevalence, proceeding in asymptomatic patients should be in designated isolation rooms with full precautions for aerosol generation.[49] The aforementioned principles apply for bronchoscopy in the ICU setting as well.

Interventional Gastroenterology

Upper gastrointestinal endoscopies are also deemed aerosol-generating interventions, and there are suggestions that the virus may be present in fecal and gastrointestinal secretions.[48,52] Aerosolization may happen during scope insertion into the pharynx as well as during manipulation of instruments through the endoscope's channel.[53] Esophageal intubation with the endoscope often requires positive gas insufflation, which is also a risk factor for aerosol generation.[54] Only urgent or semiurgent interventions are likely to be performed during the COVID-19 pandemic as per the position statements from governing organizations.[55]

In known or suspected cases, GETA should be the first choice. Practitioners from Wuhan have described using wet gauze to cover the area around the nose and mouth while intubating confirmed cases to reduce droplet spread.[36] This technique can be adapted during endoscopy whereby a wet soft cloth/gauze could be used to gently seal the space between the endoscope and the bite block without hindering the proximal manipulation of the endoscope. Ensuring adequate neuromuscular paralysis and administration of an antisialagogue and antiemetics can help reduce droplet spread and possible virus aerosolization. Other aerosol limiting considerations include esophageal intubation without gas insufflation (if feasible), sealing the biopsy channel with a soft cloth or air suctioning[56] while removing instruments and stopping gas insufflation as the endoscope is withdrawn from the oropharynx.

Patients without suspicion of COVID-19 may present for interventions where tracheal intubation is not indicated, for example, biliary sepsis/obstruction for an endoscopic retrograde cholangiopancreatography without aspiration/difficult airway risk. In such instances, the prevalence rate in the community and opinion from local infectious disease specialists should be considered in choosing the appropriate technique. Sedation techniques with adequate airborne PPE precautions may be an appropriate choice for less complex cases.

Interventional Cardiology Procedures

Cardiology organizations have issued statements regarding deferring all nonurgent interventions.[57] Transesophageal echocardiography (TEE) has a high risk of aerosolization and droplet spread similar to upper gastrointestinal endoscopic procedures.[57] It is indicated only as an urgent in-patient diagnosis that will alter clinical management (eg, high suspicion of endocarditis).[57] If warranted for known or suspected cases, the procedure is best conducted under GETA either within the negative pressure rooms in ICU or at a dedicated operating room. GETA is a safe option not only to minimize aerosol generation from TEE but also in having a secured airway in the event of an unforeseen cardiopulmonary resuscitation (CPR) and intubation requirement.[58] A small number of urgent transcatheter cardiac valve replacements, device closure interventions, and percutaneous coronary interventions are also likely to be encountered. If the diagnosis is unknown, a vigilant sedation technique with full airborne PPE may be an appropriate choice. If the intervention suite is not conducive for airway interventions, it is best to secure the airway in a specifically designated operating room if located in close proximity. This may not be feasible, and airway interventions may need to be performed in the suite, with adaptations to existing workflow as per local guidelines.

Diagnostic and Interventional Radiology

An anteroom may need to be established in the radiology suite. For known or suspected cases, GETA should be an appropriate choice. Prolonged interventions may benefit from judicious use of muscle relaxants. For urgent cases where the diagnosis is unknown, sedation techniques can be carefully used under airborne PPE precautions. Existing workflows may need to be utilized, for example, to avoid lengthy intrahospital transfers, and altered as per local recommendations.

Electroconvulsive Therapy

BMV and cough during electroconvulsive therapy (ECT) can potentially disperse droplets and aerosols. The procedure should not be performed on confirmed cases. New treatment or an interrupted treatment cycle should only be commenced if the patient becomes asymptomatic after a waiting period of 14 days and a subsequent negative test result (as per institutional guidelines), and if ECT is deemed as a life-saving procedure.[59] Adequate preoxygenation and apneic oxygenation using nasal prongs are options to reduce mask ventilation. Hyperventilation using BMV should be avoided unless other means to improve seizure quality are ineffective. If hyperventilation is warranted, a SGA can be considered instead of BMV.[59] Options to reduce periprocedural secretions and cough include intravenous glycopyrrolate, lidocaine, and remifentanil.[59]