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

Other Disciplines/Scenarios

Obstetric Anesthesia

This topic has recently been reviewed in great detail.[60] Neuraxial techniques avoid general anesthesia and are recommended. Both early epidural analgesia and spinal analgesia for lower segment cesarean sections are considered safe in COVID-19 patients. Currently, information is limited regarding cleaning, filtering, and possible aerosolization with the use of nitrous oxide (as per the Society of Obstetric Anesthesia and Perinatology [SOAP]).[61] Based on this, SOAP suggests that individual labor units should review the risks and benefits and consider suspending the use of nitrous oxide.[61] Cesarean deliveries should be performed in operating rooms modified for COVID-19 patients. If general anesthesia is warranted, general principles of airway management applicable for a known COVID-19 case should be followed.[60] After delivery, the baby should be temporarily separated from the mother.[62] Currently, there is a lack of evidence to support vertical transmission occurring;[63] however, the theoretical risk of transmission after birth via respiratory droplets is feasible. Simulating the workflows and creating dedicated kits with equipment and drugs required for labor analgesia and cesarean deliveries are recommended to prevent contamination.[37]

Cardiopulmonary Resuscitation

CPR involves chest compressions, mask ventilation, suctioning, and intubation, all of which are aerosol generating.[8] PPE applicable to aerosol-generating procedures should be worn, and minimal number of personnel should be involved.[64] Chest compression-only CPR should be commenced initially.[64] Mouth-to-mouth ventilation and expired air resuscitation masks are not recommended.[64] BMV should be minimized with apneic oxygenation techniques used instead if feasible.[10] It is recommended to secure the airway (tracheal intubation) early in resuscitation to minimize aerosol generation. Existing supplemental oxygen delivering devices should be left in place. If they are not in place, a facemask applied beneath a surgical mask has been recommended.[64] Chest compressions should be ceased during intubation or SGA insertion.[10,12] Use of mechanical external chest compression devices such as the Autopulse (Zoll Medical, Chelmsford, MA) or LUCAS Chest Compression System (Physio-Control, Redmond, VA) may help reduce the number of health care workers in proximity to the patient.[10,65] Familiarity, accessibility, and postcare disinfection are limiting factors of these devices.