Difficult Airway Management in Adult Coronavirus Disease 2019 Patients

Statement by the Society of Airway Management

Lorraine J. Foley, MD, MBA; Felipe Urdaneta, MD; Lauren Berkow, MD, FASA; Michael F. Aziz, MD; Paul A. Baker, MBChB, MD, FANZCA; Narasimhan Jagannathan, MD, MBA; William Rosenblatt, MD; Tracey M. Straker, MD, MS, MPH, CBA; David T. Wong, MD; Carin A. Hagberg, MD


Anesth Analg. 2021;133(4):876-890. 

In This Article


This report represents recommendations from the SAM task force for the management of the difficult airway in an adult with COVID-19.

Nonanatomic Difficult Airway Considerations in Adult COVID-19 Patients

  • A difficult airway may be present due to the inability to ventilate, intubate, oxygenate, or any combination of the preceding. The baseline incidence of the difficult airway may be increased in COVID-19 patients due to anatomical, physiological, and contextual issues.

In addition to known anatomic considerations, critically ill COVID-19 patients may have a physiologically difficult airway. These patients are often critically ill, may have already failed noninvasive positive pressure oxygenation (NIPPO/high-flow nasal oxygen [HFNO]) or ventilation, may require urgent/emergent intubation due to cardiorespiratory collapse, and are at risk of worsening hemodynamic instability during intubation.[4,5] COVID-19 patients may also develop airway edema, acute respiratory distress syndrome (ARDS), acute kidney injury, myocardial dysfunction, and coagulation abnormalities.[6–8] Under these situations, the difficulty of airway management and incidence of complications are increased. In the emergent setting outside the operating room, additional space constraints and lack of needed equipment and personnel add additional challenges.[8–10] While not all COVID-19 patients may exhibit anatomic or physiological predictors of difficulty, early recognition of the difficult airway is important to permit adequate preparation to reduce exposure risk and complications.

Risk of Aerosolization, PPE, and Intubation Team

During airway management, BMV, tracheal intubation, and extubation are aerosol-generating procedures (AGP).[1,11–14] Currently, neither the magnitude of the viral load that can be aerosolized nor the minimum infectious dose for COVID-19 has been established.[15] While the infection rate in health care providers after performing intubations in COVID-19–positive patients is unclear, studies suggest that HCWs may be at increased risk of COVID-19 infection after an airway management episode involving an infected patient.[16–19] In patients with a difficult airway, airway management may take longer and involve more HCW and aerosolizing procedures.[20] Therefore, the same or greater level of aerosol protection should apply to all airway procedures in COVID-19 patients with a difficult airway, including diligent use of PPE. Although a powered air-purifying respirator (PAPR) is the preferred level of PPE during airway management, these systems are more difficult and take more time to don than an N95 mask and face shield. Therefore, an early assessment of the need to manage the airway of a known or suspected COVID-19 patient should be made.

Additionally, airway management of a known or suspected COVID-19–infected patient should be performed in a negative pressure room, if available.[19]

Many lessons have been learned from the SARS, Ebola, and currently with the COVID-19 outbreak related to airway management, PPE, and the intubation team.[21,22] To minimize the number of HCW in the room, the intubation team should consist of highly skilled personnel to minimize the number of HCW in the room if feasible. As an illustration, an intubation team would include the following:

  1. Intubator: A provider experienced in advanced airway management techniques (increases success rate and decreases the number of personnel needed in the room).[23,24]

  2. Spotter: To help don and doff team's PPE, provide needed equipment from a difficult airway cart kept outside the patient room.

  3. Respiratory therapist (for difficult airways outside of the operating room).

  4. The second assistant to the intubator (if possible) to administer medications.

  5. The patient's nurse.

Difficult Airway Equipment. A difficult airway cart should be located directly outside of the room. The cart need not be brought into the room unless needed to minimize contamination of equipment. Equipment should include different sized endotracheal tubes (ETT), intubating supraglottic airway (SGA; preferably second generation), Macintosh and Miller blade and handle, drugs, scalpel and bougie, videolaryngoscope, and flexible intubation scope (FIS). Use of disposable equipment is preferred, if available (Figure 1).

Figure 1.

Society for Airway Management recommendations: before intubation preparation and decision to proceed with awake tracheal intubation. COVID-19 indicates coronavirus disease 2019; PAPR, powered air-purifying respirator; PPE, personal protective equipment; RSI, rapid sequence induction; SGA, supraglottic airway.

Before entering the room, the intubation team should discuss the airway management plan and verify that all equipment and medications are available ("airway time out"). Verbal communication among providers may also be more difficult while wearing a PAPR, which adds additional importance to the airway time out and clear delineation of roles.[25]

Use of PPE and adherence to appropriate PPE protocols reduces the incidence of contamination during intubation and doffing, and their use has been described elsewhere for COVID-19 intubations.[24,26–33] The effect of PPE may not only impair communication between the airway team, but studies have also shown prolonged time to intubation during airway management, which should be taken into consideration.[9–11]