Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society

Abstract

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Figure 1.

A cognitive aid summarizing the recommendations of PeDI-C for airway management of pediatric patients during the COVID-19 pandemic. AGMP indicates aerosol-generating medical procedure; COVID-19, Coronavirus Disease 2019; FONA, XXX; HEPA, high-efficiency particulate air; LMA, laryngeal mask airway; PeDI-C, Pediatric Difficult Intubation Collaborative; TIVA, total intravenous anesthesia.

Figure 2.

A depiction of transparent drapes being used as an aerosolization barrier during mask induction in a patient (A); video laryngoscopy intubation in a manikin (B); direct laryngoscopy in a real patient (C); and 3-drape technique using an anesthesia elbow and suction under the transparent drapes (D).

Figure 3.

A, Standard viral filters (red circle) present on inspiratory and expiratory limbs of an anesthesia circuit depending on manufacturer can be removed and used as a viral filter for a transport circuit for patient transport. B, Viral filter (red circle) removed from anesthesia circuit and inserted between the endotracheal tube adapter and transport circuit.

Figure 4.

A, A Mapleson D breathing circuit with an in-line suction catheter. B, A Mapleson D breathing circuit with a viral filter at the distal end. Not suitable for infants, neonates, and small children because of the dead space of the filter and potential rebreathing. C, A Mapleson D breathing circuit with a viral filter proximal to the fresh gas flow. Preferred in infants, neonates, and small children.