• Users Online: 39
  • Print this page
  • Email this page

 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 25-30

Overcoming the airway eclipse in coronavirus disease 2019 (COVID-19) pandemic

Department of Anaesthesiology, Critical Care and Pain Medicine, AIIMS, New Delhi, India

Date of Submission27-Mar-2020
Date of Acceptance01-Apr-2020
Date of Web Publication30-May-2020

Correspondence Address:
Dr. Yudhyavir Singh
Room No. 322A, JPNATC, AIIMS, New Delhi
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ARWY.ARWY_9_20

Rights and Permissions

Coronavirus disease 2019 (COVID-19) has reached pandemic proportions, with a large number of patients succumbing to the disease and numerous requiring airway interventions. It is imperative in these challenging times for medical personnel involved in airway management and general care of these patients to know about the complexities involved and what additional precautions need to be taken while securing the airway.

Keywords: Airway management, coronavirus disease 2019, intubation, preoxygenation

How to cite this article:
Garg H, Kumar S, Singh Y, Khanna P. Overcoming the airway eclipse in coronavirus disease 2019 (COVID-19) pandemic. Airway 2020;3:25-30

How to cite this URL:
Garg H, Kumar S, Singh Y, Khanna P. Overcoming the airway eclipse in coronavirus disease 2019 (COVID-19) pandemic. Airway [serial online] 2020 [cited 2020 Sep 30];3:25-30. Available from: http://www.arwy.org/text.asp?2020/3/1/25/285434

  Introduction Top

Coronavirus disease 2019 (COVID-19), as named by the World Health Organization, has reached pandemic proportions and has emerged as one of the biggest threats to humankind, posing a threat to both the common public and healthcare workers (HCW) alike. In these times, management of the airway becomes a high-risk task for HCWs, especially airway managers such as anaesthesiologists, as the chances of aerosol production and transmission are extremely high. These airborne particles may travel great distances and be inhaled, increasing the risk of transmission.[1] A close look at the recent data from Wuhan relating to 138 confirmed COVID-19 cases reveals that 41.3% was considered as acquired infection from the hospital, and more than 70% of these patients were healthcare providers.[2] COVID-19 has now been classified as a high-consequence infectious disease, which emphasises the significant risk to HCWs and the healthcare system.[3]

We believe that this review covers most of the important information that a healthcare worker, especially one who works close to the airway, needs to be aware of to ensure not only safe patient care but also personal safety. The following key messages will be emphasised throughout the review:

  • Safety of the healthcare worker should be ensured while managing a COVID-19 patient
  • All patients must be handled after donning personal protective equipment (PPE)
  • Adequate training is necessary to manage the airway with protective gear and through the plastic drapes
  • Maximum care must be exercised to minimise aerosolisation of virus particles
  • Intubation must be performed, with intubating aids being used in the initial intubation attempt itself

The do's and don'ts of airway management in a suspected or confirmed COVID-19 patient are summarised in [Appendix 1].

  Personal Protective Equipment Top

The use of PPE is imperative while handling a positive or suspected COVID-19 patient. Personal safety is of topmost priority during such times. Adequate training for donning and doffing of PPE is being provided at all medical institutions through online tutorials, webinars and personal training sessions. Wearing double gloves and removing the outer gloves after handling the patient should be followed. However, there can be multiple points of contamination before donning of PPE which can lead to infection in a HCW. Therefore, appropriate triage areas are the need of the hour in every healthcare organisation with immediate isolation of infected cases.[4] Fitted respirator masks (such as N95 mask) as opposed to the surgical masks should be used while doing any procedure which has higher chances of aerosolisation.[5] Standard Level 3 protection should be undertaken while performing tracheal intubation.[6] According to the American National Standards Institute (ANSI) and the Association of the Advancement of Medical Instrumentation (AAMI): ANSI/AAMI PB70:2003 for healthcare facilities, the process of intubation requires Level 3 protection. The recommended Level 3 protection process consists of hand disinfection, head cap, protective mask N95 1860, surgical masks, isolation gown, disposable latex gloves, goggles, protective clothing, disposable latex gloves, shoe covers, disposable gown, disposable latex gloves and full head hood.[6],[7]

  Preparation Top

A thorough but cautious airway assessment needs to be done, and a plan for securing the airway should be formulated by the team before starting the procedure. A separate single cart should be prepared to keep all the equipment required for securing the airway for COVID-19 patients. Use of disposable, single-use devices is highly recommended. Securing the airway should preferably be done in a negative pressure room.[5] If this is not possible, it should be performed in a single room with no other patients after ensuring that the door is closed. If no room is available, isolate the patients and maintain a distance of 2 metres between other patients and the HCW. A bacterial and viral filter should be attached between the mask and the circuit. Closed circuits should be used at all places, preferably with the anaesthesia workstation, but in the intensive care unit, it will be a limiting factor. Only a minimum number of essential staff should be present in the room. They also should enter the room one by one.[1],[7] Effective ways of communication should be made feasible prior to entering the room such as addition of a speaker or making use of sign language. Medications should be pre-prepared, labelled and placed on the cart. Disposable clear plastic drapes should be available to cover the patient's face, and all the airway equipment should be kept on this drape. The drape will provide an additional layer of protection between the patient's airway and the airway of the HCW, there by limiting the spread of aerosols.[8]

  Preoxygenation Top

Preoxygenation with 100% oxygen for 3 min with tidal volume breaths or 8 vital capacity breaths in 1 min helps increase the apnoea time and delay desaturation. While most of the afflicted patients may only have upper respiratory tract involvement, elderly patients or people with various comorbidities can present with lower respiratory tract involvement. It can also be superimposed on an already-affected lung due to chronic obstructive pulmonary disease or chronic lung disease. The coronavirus damages both the wall and lining cells of the alveolus as well as the capillaries. The debris that accumulates because of all that damage lines the wall of the alveolus.[5] Significant pulmonary disease is associated with a decreased functional residual capacity, thereby decreasing the margin of safety. Patients with COVID-19 with respiratory distress might need 5 or more minutes of tidal volume breathing for adequate preoxygenation. The mask used for preoxygenation should provide an effective seal.[9]

Manikin studies show that there is minimal dispersal of exhaled air when noninvasive ventilation (NIV) or high-flow nasal cannulae (HFNC) are optimally fitted and significantly less than that caused by the coughing and sneezing.[10],[11] However, the specific NIV and HFNC models which were tested are not universally used across all the hospitals. Oxygen therapy devices which use flows of 6 L/min or more are considered high flow and will add to expired air dispersion and hence are also not recommended.

Apnoeic diffusion oxygenation is another method of preoxygenation. This is usually done by maximal face mask preoxygenation followed by oxygen insufflation up to 15 L/min through a nasopharyngeal or an oropharyngeal cannula or through a needle inserted through the cricothyroid membrane.[9] Although oxygenation can be maintained for longer periods, it is unknown at present whether this technique can be used in COVID-19 patients as flows exceeding 5 L/min are not recommended due to creation of aerosols.

  Use of Drugs Top

One of the prerequisites in airway management in COVID-19 patients is to ensure smooth intubation and avoid any coughing or straining to minimise the aerosol generation and to decrease the fogging of the laryngoscope. The choice of induction drug is dictated by haemodynamic considerations. Etomidate, propofol or ketamine can be used for induction based on the patient's haemodynamic status. Etomidate may be preferred in view of better cardiovascular stability. With regard to the choice of neuromuscular blocking agents, both rocuronium and suxamethonium can be used effectively as relaxant in such patients.[10],[11] When rocuronium is used, it should be given in a full dose of 1.2 mg/kg to achieve a quick onset time such as that obtained with suxamethonium. Some prefer using rocuronium over suxamethonium due to its longer half-life. If the first intubation attempt fails, this may lead to coughing and further aerosolisation should the patient be recovering from suxamethonium by then. Use of neuromuscular blocking agents ensures apnoea and prevention of coughing during airway interventions, thereby minimising the risk of aerosol generation while the airway management team is in close proximity to the patient's airway.[12]

  Mask Ventilation Top

Positive pressure ventilation (PPV) can generate aerosols at a high rate due to an ineffective seal and should be avoided as far as possible.[13] Rapid sequence induction should be the technique of choice. If at all bag mask ventilation (BMV) is needed, a two-handed technique to obtain a secure mask fit is advisable as it minimises the leak around the seal and gentle ventilation should be provided using small tidal volumes.[10],[11],[12] If we are performing intubation using a self-inflating bag for providing ventilation, a high-efficiency particulate air filter should be used between the mask and the self-inflating bag.[1]

  Intubation Top

Advanced countries advocate the use of a videolaryngoscope.[1],[10],[12] However, in a resource-limited country such as India, the use of a videolaryngoscope as a first choice seems out of question. In such a scenario, extra precautions need to be taken by HCWs to avoid the risk of contamination. The person who is performing the intubation should preferably wear an extra pair of gloves and remove them immediately after intubation. Intubating aids such as a gum elastic bougie and an intubating stylet should be made available early. To minimise the number of intubation attempts, it is better to plan the first intubation with the use of intubation aids. Confirmation of correct placement of an endotracheal tube should be done by waveform capnography and visible chest rise (and not by auscultation or misting of the tube). Stethoscopes should be avoided as it will be difficult to use after donning the head shield and will be a source of infection. In the emergency department where capnography is not available, disposable colorimetric devices such as a Fenem detector can be used to confirm correct tracheal placement. Ultrasound can also be used to confirm intubation, but it should not take priority over other methods of confirmation. However, these modalities may also not be available in many resource-limited areas, and reliability on clinical signs becomes imperative. The cuff should be immediately inflated to minimise leakage of expired gases with an unpredictable viral load. Intubation should be done by the most experienced anaesthesiologist on the team to minimise the airway contact, preferably employing the technique that (s)he is most familiar with.[8] Awake fibreoptic intubation is not recommended because of the involved risk of aerosolisation that may occur during topicalisation and accompanying coughing. The ventilator end of the endotracheal tube should be covered with a small strip of a non-porous plaster such as Durapore™ or Micropore™ during the intubation process so as to minimise aerosolisation. This plaster is removed just before connecting to the ventilator. In addition, the filter or catheter mount are connected to minimise the aerosols. These techniques are an extension of the technique which was developed during the management of patients with swine flu.

  Supraglottic Airway Device Top

As the supraglottic airway device (SAD) does not ensure a seal that is as effective as an endotracheal tube, it leads to more aerosolisation and hence should be avoided in patients with COVID-19 infection.[13] Moreover, patients with poor pulmonary compliance are not good candidates for SAD placement. However, Cheung et al have advocated that SAD insertion and gentle ventilation through it may still be better than BMV if at all patient needs to be ventilated prior to securing the airway. Ease of insertion and achievement of a good sealing pressure provides the SAD an edge over BMV.

SADs also help in reducing the workforce required and thus staff exposure. Newer generation SADs can also act as a conduit to aid in intubation.[10] A single-use SAD should be preferred in such patients because of the problems associated with decontamination and sterilisation. Disposable equipment may prove to be a limiting factor in resource-poor countries and even in advanced countries where the disease has reached pandemic proportions.

  Suction Top

Suctioning is important to keep the airway clear of secretions so as to improve our vision while securing the airway. Open airway suctioning should be avoided as far as possible. Closed suction systems are recommended to minimise aerosol generation.[12] Nasogastric tube placement, if needed, should be done after the patient is intubated to avoid aerosolisation.

  Unanticipated Difficult Airway Top

If a difficult airway is encountered, our first reflex is to start PPV using a mask. This should be strictly avoided. External laryngeal manipulation, bougie or an optical stylet may improve the chances of successful tube placement and should be applied early during the first intubation attempt. Repeated tracheal intubation attempts can increase aerosol generation and viral spread. A second-generation laryngeal mask airway (LMA) should be inserted after an intubation failure.[12] Tracheal intubation can be achieved through the LMA with the guidance of a fibreoptic bronchoscope.[8]

If tracheal intubation, face mask ventilation and SAD insertion have failed, a situation of complete ventilation failure has occurred.[14] In this situation, it is prudent to immediately proceed to emergency surgical access to ensure ventilation. A cricothyroidotomy may be performed using either a cricothyroidotomy kit or a scalpel technique (a scalpel with number 10 blade, a bougie and a 5.0 mm ID or 6.0 mm ID cuffed endotracheal tube). The scalpel-bougie technique minimises the risk of viral aerosolisation, which can happen if high-pressure oxygen insufflation is done through a small bore cannula.[12] Needle cricothyroidotomy is not recommended.

  Extubation Top

Ideally, patients should be extubated in a negative pressure room or the patient should be shifted to such a room. A negative pressure room should be available for this purpose. One should minimise the staff during extubation.[2],[12] Proper antiemetic prophylaxis should be given to avoid retching, nausea and coughing, and adequate analgesia must also be ensured. Extubate patients and apply a face mask with a bacterial–viral filter attached immediately as they are likely to cough. A face tent can also be used. Avoid extubation if the patient is likely to require ventilatory support. Use of HFNC and bilevel positive airway pressure is not advised.

  Noninvasive Ventilation Top

Noninvasive ventilation (NIV) is not recommended for COVID-19 patients with a high viral load.[12] A good mask seal is extremely important during NIV to limit the dispersion of exhaled particles. This is not possible in every patient, and the availability of perfectly fitting masks is also limited. Both the need for a stringent PPE check for the HCW and a negative pressure room to care for a patient on NIV pose problems for the use of NIV. Furthermore, the efficacy of NIV in the presence of acute respiratory distress syndrome is questionable.[15]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Peng PWH, Ho PL, Hota SS. Outbreak of a new coronavirus: what anaesthetists should know. Br J Anaesth. 2020;S0007-0912:30098-2. doi:10.1016/j.bja.2020.02.008.  Back to cited text no. 1
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 2
High Consequence Infectious Diseases. Available from: https://www.gov.uk/guidance/high-consequence-infectious- diseases-hcid. [Last accessed on 2020 Mar 10].  Back to cited text no. 3
World Health Organization. Novel Coronavirus (2019-nCoV) Technical Guidance: Infection Prevention and Control. Available from: https://www.who.int/emergencies/ diseases/novel-coronaviru-2019/technical-guidance/ infectionprevention-and-control. [Last accessed on 2020 Mar 10].  Back to cited text no. 4
Alhazzani W, Moller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: Guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). [published online ahead of print, 2020 Mar 27]. Crit Care Med. 2020;10.1097/CCM.0000000000004363. [doi. org/10.1007/s00134-020-06022-5].  Back to cited text no. 5
Luo M, Cao S, Wei L, Tang R, Hong S, Liu R, et al. Precautions for Intubating Patients with COVID-19. Anesthesiology 2020;No Pagination Specified. doi: https://doi.org/10.1097/ALN.0000000000003288. [Published online ahead of print,2020 Mar 26].  Back to cited text no. 6
Chen X, Liu Y, Gong Y, Guo X, Zuo M, Li J, et al. Perioperative management of patients infected with the novel coronavirus: Recommendation from the Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists. Anesthesiology 2020;No Pagination Specified. doi: https://doi.org/10.1097/ALN.0000000000003301. [published online ahead of print,2020 Mar 27].  Back to cited text no. 7
Zuo MZ, Huang YG, Ma WH, Xue ZG, Zhang JQ, Gong YH, et al. Expert recommendations for tracheal intubation in critically ill patients with noval coronavirus disease 2019. Chin Med Sci J 2020;10.24920/003724. doi:10.24920/003724. [Published online ahead of print, 2020 Feb 27].  Back to cited text no. 8
Nimmagadda U, Salem MR, Crystal GJ. Preoxygenation: Physiologic Basis, Benefits, and Potential Risks. Anesth Analg 2017;124:507-17.  Back to cited text no. 9
Cheung JC, Ho LT, Cheng JV, Cham EY, Lam KN. Staff safety during emergency airway management for COVID-19 in Hong Kong. Lancet Respir Med 2020;8:e19.  Back to cited text no. 10
Chang D, Xu H, Rebaza A, Sharma L, Cruz CS. Protecting health-care workers from subclinical coronavirus infection. Lancet Respir Med 2020;8:e13. [doi.org/10.1016/ S2213-2600 (20) 30066-7].  Back to cited text no. 11
Brewster DJ, Chrimes NC, Do TB, Fraser K, Groombridge CJ, Higgs A, et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. Med J Aust. 2020:2020-03.  Back to cited text no. 12
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.  Back to cited text no. 13
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.  Back to cited text no. 14
[PUBMED]  [Full text]  
Ñamendys-Silva SA. Respiratory support for patients with COVID-19 infection. Lancet Respir Med 2020;8:e18.  Back to cited text no. 15


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Personal Protect...
Use of Drugs
Mask Ventilation
Supraglottic Air...
Unanticipated Di...
Noninvasive Vent...

 Article Access Statistics
    PDF Downloaded120    
    Comments [Add]    

Recommend this journal