Airway Management in the Operating Room and Interventional Suites in Known or Suspected COVID-19 Adult Patients: A Practical Review

Abstract

Current evidence suggests that coronavirus disease 2019 (COVID-19) spread occurs via respiratory droplets (particles >5 µm) and possibly through aerosol. The rate of transmission remains high during airway management. This was evident during the 2003 severe acute respiratory syndrome epidemic where those who were involved in tracheal intubation had a higher risk of infection than those who were not involved (odds ratio 6.6). We describe specific airway management principles for patients with known or suspected COVID-19 disease for an array of critical care and procedural settings. We conducted a thorough search of the available literature of airway management of COVID-19 across a variety of international settings. In addition, we have analyzed various medical professional body recommendations for common procedural practices such as interventional cardiology, gastroenterology, and pulmonology. A systematic process that aims to protect the operators involved via appropriate personal protective equipment, avoidance of unnecessary patient contact and minimalization of periprocedural aerosol generation are key components to successful airway management. For operating room cases requiring general anesthesia or complex interventional procedures, tracheal intubation should be the preferred option. For interventional procedures, when tracheal intubation is not indicated, cautious conscious sedation appears to be a reasonable approach. Awake intubation should be avoided unless it is absolutely necessary. Extubation is a high-risk procedure for aerosol and droplet spread and needs thorough planning and preparation. As updates and modifications in the management of COVID-19 are still evolving, local guidelines, appraised at regular intervals, are vital in optimizing clinical management.

Figure 1.

Layout of the airway intervention suite. Adapted and modified from Brewster et al. COVID indicates Coronavirus Disease 2019; HEPA, high-efficiency particulate air.

Figure 2.

Components of standard airborne precaution personal protective equipment. Adapted and modified from Centers for Disease Control and Prevention.

Figure 3.

PPE guidelines for anesthesiologists. AGP indicates aerosol-generating procedure; BiPAP, xxx; COVID-19, Coronavirus Disease 2019; CPAP, xxx; PPE, personal protective equipment; SARS-CoV-2, severe acute respiratory syndrome Coronavirus 2; SGA, supraglottic airway.

Figure 4.

Airway management for known or suspected COVID-19 patients. COVID indicates Coronavirus Disease 2019; Etco₂, xxx; Eto₂, expired O₂ concentration; ETT, endotracheal tube; HEPA, high-efficiency particulate air; IV, xxx; PPE, personal protective equipment; PPV, positive pressure ventilation; RSI, xxx; SGA, supraglottic airway.