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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 79-84

Awake tracheal intubation during COVID-19 pandemic: An audit of 23 cases in a tertiary cancer centre

Tata Medical Center, Kolkata, West Bengal, India

Date of Submission10-Dec-2020
Date of Acceptance02-Jul-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Rudranil Nandi
Tata Medical Center, 14 MAR, Kolkata - 700 156, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_58_20

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Background: Coronavirus disease 2019 (COVID-19) pandemic has significantly affected routine healthcare including cancer care across the world. Head and neck cancer (HNC) is the most common cancer in India and has a good prognosis if treated surgically in early stages. HNC patients often present with difficult airway with reduced mouth opening requiring awake tracheal intubation (ATI). Health professionals are at a risk of getting infected with COVID-19 during ATI, a potential aerosol-generating procedure. We aimed to evaluate the modifications of ATI techniques used during the COVID-19 pandemic in our institution. Methodology: This retrospective observational study was conducted in a tertiary cancer care centre. All patients who had ATI performed between 25th March 2020 and 31st May 2020 were included in the study. The type of barrier methods used to prevent aerosol spread and the methods used to provide topical anaesthesia of the airway were documented and analysed. Results: Twenty-three patients underwent ATI during that period. Barrier methods such as aerosol box or transparent plastic drapes to prevent aerosol spread were used in 48% of patients. Lignocaine nebulisation and transtracheal lignocaine injection were administered in 70% and 87% of patients, respectively, during the study period. Spray-as-you-go lignocaine topicalisation and oral lignocaine spray for airway topicalisation were used in 22% and 39% of patients, respectively, during this period. Five techniques were used for ATI – conventional, under aerosol box (single anaesthesiologist and two anaesthesiologists) and under transparent plastic drape (in one technique, both airway topicalisation and intubation were done under the drape; in another, only intubation was performed under the drape). Conclusions: With modifications of the routine technique, ATI can be performed safely during the COVID-19 pandemic.

Keywords: Aerosol box, awake fibreoptic-guided intubation, awake tracheal intubation, coronavirus disease 2019 pandemic, plastic drapes, prevention of viral aerosol spread

How to cite this article:
Nandi R, Bhajikhav K, Gupta N, Pal AR, Desai N, Goswami J. Awake tracheal intubation during COVID-19 pandemic: An audit of 23 cases in a tertiary cancer centre. Airway 2021;4:79-84

How to cite this URL:
Nandi R, Bhajikhav K, Gupta N, Pal AR, Desai N, Goswami J. Awake tracheal intubation during COVID-19 pandemic: An audit of 23 cases in a tertiary cancer centre. Airway [serial online] 2021 [cited 2022 Jan 27];4:79-84. Available from: https://www.arwy.org/text.asp?2021/4/2/79/323582

  Introduction Top

The world has been passing through the coronavirus disease 2019 (COVID-19) pandemic, an unprecedented medical emergency, for more than a year now. India with its 1.35 billion population is seeing more than 3 crore confirmed cases as on 28th June 2021.[1] The footprint of COVID-19 has spread to all states including the state of West Bengal, which has seen around 15 lakh cases with 17,644 deaths to date.[1] Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative organism of COVID-19, is transmitted through aerosol and fomites generated from the airway secretions of an infected individual.[2] Healthcare workers who come in close contact with COVID-19 patients have a huge risk of getting infected if proper precautions are not taken. Thousands of healthcare workers have also been infected and died during the ongoing coronavirus outbreak.[3]

In India, head and neck cancers (HNCs) constitute the most common cancer in men compared to western countries (where it is the 6th highest), mainly due to the consumption of tobacco.[4],[5] If these cancers are operated in the early stages, a reasonable outcome is expected after appropriate adjuvant therapy.[6] Delaying surgery for even 1 or 2 months due to the pandemic may lead to the need for more extensive surgery at a later date or may even make the condition inoperable.[7] In the initial phase of the pandemic, all elective surgical procedures were deferred considering the risk of infection transmission and the need to conserve all available medical resources for patients with COVID-19. In our stand-alone cancer centre, HNC speciality continued to perform surgical procedures without any interruptions attributable to the pandemic.

Oral cancers, especially of the buccal mucosa, are often associated with reduced mouth opening making airway management difficult.[8] Awake tracheal intubation (ATI) is the gold standard in this scenario. In a resource-poor setting, an elective tracheostomy may also be considered.[8] However, both tracheostomy and ATI are considered high-potential aerosol-generating procedures (AGPs). Hence, some modifications of our conventional technique to perform ATI were warranted to ensure safety of the healthcare professionals working in the operating room (OR). Several national and international societies have issued advisories and guidelines on airway management during the COVID-19 pandemic, with special mention to avoid ATI.[9],[10] However, in patients of HNC with very limited mouth opening, awake airway intervention is the only option other than tracheostomy. Against this background, we decided to do a retrospective audit on ATIs which were performed in our institute during the COVID-19 pandemic. This audit describes the modifications which we adopted during the COVID-19 pandemic to prevent viral aerosol spread both during airway topicalisation and tracheal intubation.

  Methodology Top

As the number of COVID-19 cases were rising, the Government of India ordered a nationwide lockdown on 24th March 2020 after a day-long successful voluntary lockdown on 22nd March.[11] After obtaining approval from the Institutional Review Board, all patients who underwent ATI during the period between 25th March 2020 and 31st May 2020 were included in this audit. Data were collected from electronic medical records of the hospital management system software and patients' charts. Methods of airway topicalisation, preventive barriers used against aerosol exposure, address of the patient (whether coming from red zone or not) and any other complications that occurred were noted and analysed.

  Results Top

A total of 23 ATIs were done through the nasal route during the study period in our centre. Demographics, airway parameters, disease type and surgeries are summarised in [Table 1].
Table 1: Details of airway assessment and airway anaesthesia techniques in awake fibreoptic bronchoscope-guided intubation

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Two techniques were mainly used to prevent aerosol spread - the aerosol box and a transparent plastic drape - during performance of ATI. In 52% of patients, we did not use either of these methods mostly because we did not have access to the aerosol box in the initial phase of epidemic. A typical aerosol box has three openings, two in the front and one on the right side for the assistant. To perform flexible bronchoscope (FB) guided endotracheal intubation, we created one extra opening in the roof of the box to pass the FB. While using a transparent plastic drape, one small opening 2 cm in diameter was created. All the steps of ATI such as placement of local anaesthetic-soaked nasal cotton pledgets, spraying of lignocaine inside the oropharynx, administering a transtracheal block and performing endotracheal intubation were performed through this small opening. In some cases, airway topicalisation was done conventionally without any barrier, while endotracheal intubation was performed under the plastic drape.

Lignocaine nebulisation, a potential aerosol AGP, was used to achieve airway anaesthesia in 70% of patients. Previously, all patients scheduled to undergo an ATI used to receive nebulised local anaesthetic as part of the airway preparation. However, after the COVID-19 pandemic started, the use of lignocaine nebulisation had come down. During the pre-COVID-19 era, patients received nebulisation in the preoperative holding area before being shifted into the OR as per the institutional protocol. After the COVID-19 outbreak, our institutional practice has changed to lignocaine nebulisation being administered after shifting the patient into the OR.

Spray-as-you-go (SAYGO) was not widely practised during the pre-COVID era in our institute. However, after the COVID-19 pandemic started, some anaesthesiologists have started avoiding lignocaine nebulisation and transtracheal block and relied either totally or partially on SAYGO for airway anaesthesia. In 22% of our patients, SAYGO was one of the methods of airway topicalisation [Table 2]. When SAYGO was performed under a transparent plastic drape, patients coughed under the drape which possibly limited the aerosol spread to within the drape.
Table 2: Airway anaesthesia techniques

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Transtracheal block was administered in 87% of patients during the COVID pandemic. In the pre-COVID era, every patient used to receive the block as per our institutional protocol. As this block almost always initiates the patient to cough, anaesthesiologists started avoiding this method of airway anaesthesia after the COVID-19 outbreak. Initially, in a few cases, transtracheal blocks were given without using any aerosol barrier method. However, after the aerosol box and transparent plastic drape became available for regular practice, the block was performed quite safely under the barrier without significant aerosol spread.

We used five different techniques to perform ATI. During the early phase of the pandemic, conventional techniques were used with no special precautions to prevent the spread of aerosol. In the later phase, we introduced the plastic drape and the aerosol box into our practice.

We used plastic drapes in one of two ways. In the first method, airway preparation was done without the plastic drape, while ATI was done through a small opening (approximately 2 cm in diameter) made in the plastic sheet covering the patient's face [Figure 1]. In the second method, the patient's face was covered with a transparent plastic drape after the patient entered the OR. Airway topicalisation methods such as lignocaine nebulisation, transtracheal block and oral lignocaine spray were performed under the plastic drape [Figure 2]. A small opening about 2 cm in diameter was created in the plastic drape. This opening was positioned over the nostril to facilitate the passage of cotton pledgets soaked with 4% lignocaine and adrenaline through both nostrils. Following this, the plastic drape was moved caudally so that the opening was now centred over the mouth. Puffs of lignocaine spray (10%) were used targeting the posterior pharyngeal wall. The plastic drape was then moved further down so that the opening was over the cricothyroid membrane through which 4 mL of 2% lignocaine was injected transtracheally with a 22 SWG intravenous cannula. Eventually, the opening of the plastic cover was placed over the nostril again, and the FB, preloaded with an appropriately sized flexometallic endotracheal tube, was negotiated through the nasal cavity. As the epiglottis and the vocal cords were visualised, 3 mL of 2% lignocaine was sprayed on to the vocal cords through the working channel of the bronchoscope. After waiting for 30 s, the FB was negotiated through the glottic inlet and the endotracheal tube railroaded over the bronchoscope [Figure 2]. The cuff was inflated, the bronchoscope removed and the ventilator circuit was quickly attached to the proximal end of the tube. After confirmation of tube position by capnography, general anaesthesia was induced.
Figure 1: (a) Patient's face covered with a transparent plastic drape-oxygen mask can be appreciated under the plastic drape; (b) an opening in the plastic drape over the nostril, oxygen mask was displaced a bit caudally; (c) nasal endotracheal tube in place through the opening in the plastic drape

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Figure 2: (a) Nasal fibreoptic bronchoscope-guided endotracheal intubation with patient covered by a plastic drape; (b) transtracheal injection through the opening in the plastic drape; (c) placement of cotton pledgets inside nose

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In the aerosol box method, the box was placed over patient's face and all airway preparation measures such as lignocaine atomisation/nebulisation, transtracheal block, application of local anaesthetic-soaked nasal pledgets, oropharyngeal spray with 10% lignocaine and instillation of 0.1% w/v xylometazoline drops into both nostrils were undertaken within the aerosol box. With our initial experience, we found that it could be a bit difficult for one performer to negotiate the fibreoptic bronchoscope (FOB) inside the aerosol box. Hence, we switched to a two-anaesthesiologist technique where one anaesthesiologist (intubator) handled the FOB outside the box while a second anaesthesiologist (assistant) inserted the bronchoscope through nostrils [Figure 3]. Once the FOB entered the glottis, the tip was advanced till it reached a few centimetres above the carina, and the flexometallic endotracheal tube was railroaded by the first anaesthesiologist into the box from outside, while the second anaesthesiologist advanced it further into the airway. In this audit, it was found that the conventional technique with no specific precautions against the spread of viral aerosol was used in 52% of patients, whereas aerosol box and transparent plastic drape were used in 26% and 22% of patients, respectively.
Figure 3: (a) Awake tracheal intubation using aerosol box - two-anaesthesiologist technique; (b) Awake tracheal intubation using aerosol box – one-anaesthesiologist technique

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  Discussion Top

As soon as the World Health Organization declared COVID-19 as a pandemic in the month of March 2020, several international and national societies and organisations released advisories regarding elective surgical procedures and airway management in COVID-affected individuals. Cancer surgeries were advised to be deferred depending on cancer biology and appropriate alternative therapy.[12] However, for HNC, surgical intervention is a curative treatment with high success rate unlike other modalities of treatment. As far as airway management was concerned, the recommendation was to avoid ATI.[9],[10] However, HNC patients very often present with a difficult airway where awake airway management is the only safe option.

Healthcare workers learn from each other, especially during periods of crisis. Hence, we describe this audit of 23 cases of ATI using the FOB. We modified our techniques as described above especially targeting airway anaesthesia methods and adding some techniques to prevent the spread of viral aerosol. We searched in PubMed®, Google Scholar and Medline® with the keywords awake tracheal intubation during COVID-19 pandemic and awake fibreoptic guided intubation during COVID-19 pandemic. Only one case report was published at the time of writing this manuscript. Ahmad et al. described the technique of ATI in a patient with tongue cancer who was posted for tracheostomy because of critical airway obstruction.[13] The patient was also suspected to be infected with the novel SARS-CoV-2. The authors created an opening in the Hudson's oxygen mask to negotiate the FOB into the airway while continuing oxygen therapy during the procedure. They sedated the patient with target-controlled infusion (TCI) of propofol and remifentanil before any airway anaesthesia procedure was performed. After conscious sedation was established, they topicalised the nasopharynx and oropharynx with 2.5 mL co-phenylcaine (lignocaine + phenylephrine) and twenty sprays of 10% lignocaine via a mucosal atomiser device respectively. They avoided transtracheal lignocaine injection and SAYGO lignocaine topicalisation over the vocal cords to minimise coughing and aerosol generation. They relied more on optimal sedation than local anaesthesia to minimise the cough reflex. In our audit of 23 patients, 26% of patients received sedation mainly with fentanyl, especially those patients where an aerosol barrier method (in the form of aerosol box or transparent plastic drape) was not used. When these aerosol barriers were used, during transtracheal injection or SAYGO local anaesthetic topicalisation, aerosol spread was substantially reduced inside the OR. Propofol–remifentanil infusion reduces the cough reflex, but improper dosing of these drugs, especially where TCI is not available, can lead to life-threatening airway emergencies in patients with a difficult airway. Thus, optimal topicalisation is always preferred to sedation when ATI is attempted in patients with an anticipated difficult airway. Difficult Airway Society guidelines for ATI also recommends against the use of sedation as a substitute for inadequate airway topicalisation.[14] Nebulisation and high-flow nasal oxygenation (HFNO) when available were used routinely in almost every patient. We did not use HFNO in any patient in the initial phase of the pandemic as its utility was not very clear at that point in time. Nebulisation was used in 70% patients, especially in the initial cases when aerosol barrier methods were not available or popular among the anaesthesiologists of our institute. Besides airway management-related modifications, using proper personal protective equipment was also ensured inside the OR. All healthcare professionals who were present during awake intubation mandatorily used an impervious gown, face shield, cap and N95 mask. Moreover, a negative RT-PCR for COVID-19 from the throat swab of the patient within the last 48 h had been made a prerequisite for proceeding for an elective surgical procedure in our institute after 15th May 2020. At the time of writing this manuscript in June 2020, no healthcare professional who has worked in the OR in the last 3 months has developed any symptom suggestive of COVID-19.

  Conclusions Top

After taking proper precautions and modifications of routine technique, awake FB-guided intubation can be performed safely during the COVID-19 pandemic.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Coronavirus in India: Latest Map and Case Count. Available from: https://www.covid19india.org. [Last accessed on 2021 Jun 28].  Back to cited text no. 1
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Zhan M, Qin Y, Xue X, Zhu S. Death from COVID-19 of 23 health care workers in China. N Engl J Med 2020;382:2267-8.  Back to cited text no. 3
Niaz K, Maqbool F, Khan F, Bahadar H, Hassan FI, Abdollahi M. Smokeless tobacco (Paan and Gutkha) consumption, prevalence, and contribution to oral cancer. Epidemiol Health 2017;39:e2017009.  Back to cited text no. 4
Mishra A, Meherotra R. Head and neck cancer: Global burden and regional trends in India. Asian Pac J Cancer Prev 2014;15:537-50.  Back to cited text no. 5
Hamoir M, Holvoet E, Ambroise J, Lengelé B, Schmitz S. Salvage surgery in recurrent head and neck squamous cell carcinoma: Oncologic outcome and predictors of disease free survival. Oral Oncol 2017;67:1-9.  Back to cited text no. 6
Gupta A, Arora V, Nair D, Agrawal N, Su YX, Holsinger FC, et al. Status and strategies for the management of head and neck cancer during COVID-19 pandemic: Indian scenario. Head Neck 2020;42:1460-5.  Back to cited text no. 7
Nagarkar R, Kokane G, Wagh A, Kulkarni N, Roy S, Tandale R, et al. Airway management techniques in head and neck cancer surgeries: A retrospective analysis. Oral Maxillofac Surg 2019;23:311-5.  Back to cited text no. 8
Patwa A, Shah A, Garg R, Divatia JV, Kundra P, Doctor JR, et al. All India difficult airway association (AIDAA) consensus guidelines for airway management in the operating room during the COVID-19 pandemic. Indian J Anaesth 2020;64:S107-15.  Back to cited text no. 9
Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia 2020;75:785-99.  Back to cited text no. 10
”Janta Curfew” Beginning of Long Battle: PM Narendra Modi-The Economic Times; March 22, 2020.  Back to cited text no. 11
Burki TK. Cancer guidelines during the COVID-19 pandemic. Lancet Oncol 2020;21:629-30.  Back to cited text no. 12
Ahmad I, Wade S, Langdon A, Chamarette H, Walsh M, Surda P. Awake tracheal intubation in a suspected COVID-19 patient with critical airway obstruction. Anaesth Rep 2020;8:28-31.  Back to cited text no. 13
Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2020;75:509-28.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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