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Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 63-64

The ‘hide and seek’ game of airway behind the COVID-19 mask: A new caution for anaesthesiologists

Department of Anaesthesia, Bangalore Baptist Hospital, Bengaluru, Karnataka, India

Date of Submission16-Dec-2020
Date of Acceptance11-Jan-2021
Date of Web Publication29-Apr-2021

Correspondence Address:
Dr. Reena Ravindra Kadni
Department of Anaesthesia, Bangalore Baptist Hospital, Bengaluru - 560 024, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_63_20

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How to cite this article:
Kadni RR, Zachariah K V. The ‘hide and seek’ game of airway behind the COVID-19 mask: A new caution for anaesthesiologists. Airway 2021;4:63-4

How to cite this URL:
Kadni RR, Zachariah K V. The ‘hide and seek’ game of airway behind the COVID-19 mask: A new caution for anaesthesiologists. Airway [serial online] 2021 [cited 2021 Sep 27];4:63-4. Available from: https://www.arwy.org/text.asp?2021/4/1/63/315168

Hospitals are back in action for elective procedures at practically the same pace as before. The healthcare industry has moved ahead, leaving the fears of COVID behind. Patients are seeking help for their surgical concerns. The situation has exposed all healthcare workers, especially anaesthesiologists, to new risks and challenges in their workplace.

Wearing a face mask is the new normal, and various types of masks are available as a fashion statement. The COVID-19 global pandemic situation has created awareness among the general population to wear a mask or cover the lower half of the face and neck with a shawl for self-protection. However, this has increased the difficulty in the preoperative identification of a challenging airway, possibly leading to untoward airway incidents.

Preanaesthetic evaluation (PAE) is a vital part of anaesthetic care. Examination of the airway including the neck is a mandatory aspect of PAE to avoid airway catastrophes.[1] The wearing of masks or shawls, clubbed with the hesitancy to inspect the airway, has affected the assessment of the neck and mouth of the patients. There is a definite risk of missing poor Mallampati grading, decreased thyromental distance, abnormal dentition and presence of neck swellings. In our observation, clinical assessment of thyromental distance and anatomy of the neck were commonly missed.

Thyromental distance is an important component of airway assessment which determines submandibular compliance, evidence of retrognathia or an anterior larynx. This can influence the technique of airway management. The challenge of managing the airway of a patient with COVID-19 is itself phenomenal, with several safety measures being put forth despite barriers of personal protective equipment (PPE). Inadequate airway assessment can be a result of the mask on the patient's face and the hesitancy on the part of both the patient and the doctor during this pandemic to perform a careful examination of the airway. The mandatory ‘social distancing’ norms during clinical examination creates a genuine fear in the clinician of being exposed to the aerosol generated by the patients. This could result in incomplete PAE leading to unexpected complications in the operating room like an unanticipated difficult airway.

We came across four patients planned for elective surgeries where the clinician missed decreased thyromental distance in three patients and a significant thyroid swelling in the fourth during the PAE. These findings were observed on the day of the surgery in the receiving area of the operating room, leading to these patients being labelled as having a difficult airway. The airways of the first three patients were managed uneventfully with the help of a McCoy/C-MAC blade. The fourth patient with the thyroid swelling was posted for percutaneous nephrolithotripsy in the prone position. Surgery was withheld and a computerised tomographic scan of the neck revealed a retrosternal extension of the thyroid, even though the patient was completely asymptomatic. Proceeding with the anaesthetic without identifying this issue could have resulted in a sentinel event. Inadequate airway examination during PAE, even after sliding down the mask or the shawl wrapped around the neck, was identified as the root cause for this situation.

A combination of Mallampati grading and measurement of thyromental distance was identified as the most useful bedside tests for prediction of a difficult airway.[2] A perfect, fool-proof airway assessment tool does not exist and combination of multiple tests has proven to be more useful than a single test.[3] Failure to assess and identify a potential difficult airway and application of poor judgement during airway management could lead to a poor outcome.[4]

Modification in the PAE room and wearing a complete HAZMAT suit should facilitate a proper assessment; however, the PPE itself can hinder vision and communication.[5] A focused reassessment of the patient as a ‘second-look PAE’ just before surgery can be of paramount importance. Difficult airways can go undetected despite extreme care. Readiness for every case with preformulated and practiced plans could save the day.[6]

An unanticipated difficult airway, whose management is further complicated by COVID-19 concerns, can become commonplace under present circumstances. Anaesthesiologists should be mentally and physically ready to deal with such a situation.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hung O, Law JA, Morris I, Murphy M. Airway assessment before intervention: What we know and what we do. Anesth Analg 2016;122:1752-4.  Back to cited text no. 1
Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: A meta-analysis of bedside screening test performance. Anesthesiology 2005;103:429-37.  Back to cited text no. 2
Crawley SM, Dalton AJ. Predicting the difficult airway. BJA Education 2015;15:253-7.  Back to cited text no. 3
Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. Br J Anaesth 2011;106:617-31.  Back to cited text no. 4
Bajwa SJ, Kurdi M, Stroumpoulis K. Difficult airway management in COVID times. Indian J Anaesth 2020;64 (Suppl S2):116-9.  Back to cited text no. 5
Gupta S, Rajesh Sharma KR. Jain D. Airway assessment: Predictors of difficult airway. Indian J Anaesth 2005;49:257.  Back to cited text no. 6


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