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


The SAM has developed a statement for difficult airway management of the adult patient with COVID-19. Unlike standard difficult airway guidelines, COVID-19 adds an additional dimension of provider exposure risk during intubation and extubation. Because difficult airway management may take longer than standard airway management, strict adherence to PPE protocols will reduce exposure risk to providers during difficult airway management. Optimal preoxygenation and minimizing BMV can also reduce aerosolization risk. The risks and benefits of various strategies to deliver supplemental oxygen throughout the process of difficult airway management should be considered. When a patient's airway risk assessment suggests that ATI is an appropriate choice of technique, procedures that may cause increased aerosolization of secretions should be avoided. For optimal intubating conditions, the patient should be anesthetized with full muscle relaxation before intubation. Videolaryngoscopy is recommended as a first-line strategy for airway management, assuming availability and expertise. If emergent invasive airway access is indicated, then we recommend the use of a simple surgical technique, such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. This report represents the collaborative recommendations of the management of an adult with COVID-19 and difficulties in intubation and extubation to minimize provider risk, maximize first-pass success, and maintain patient safety (Figures 1,3,4).