The Society of Airway Management recently issued guidelines for Difficult Airway Management in COVID-19 patients. The SARS CoV-2 (COVID-19) virus is extremely contagious via respiratory droplets and therefore extra precautions are needed for airway management in severe COVID-19 infection. Airway management can be difficult in COVID-19 not only because of an anatomically difficult airway, but also because of a physiologically difficult airway. A physiologically difficult airway is present if the patient has hypotension, right ventricular strain, a severe metabolic acidosis or severe hypoxic respiratory failure. In addition, many of the procedures that we use for Airway management outside of COVID-19 are aerosolizing procedures which can spread virus particles and therefore must be conducted using extreme precaution. Endotracheal intubation should ideally be conducted with a maximum of 3 people all wearing full PPE (a PAPR – powered air-purifying respirator [an N95 mask and goggles is an alternative], isolation gown, cap and gloves) in a negative pressure room.
Aerosolizing procedures include non-invasive positive pressure ventilation, bag-valve mask ventilation, bronchoscopy and high-flow nasal cannula therapy. All of these aerosolizing procedures should ideally be avoided or at most minimized. A summary of the guidelines for difficult airway management in COVID-19 patients is provided below:
- Intubations should be performed by the most experienced clinician available
- All healthcare workers should be wearing full PPE
- Intubations are ideally performed in a negative pressure room
- Personnel include an intubator, a respiratory therapist, and a nurse +/- second assistant in the room and a spotter to help provide extra equipment to the team outside the room
- The difficult airway care should be located directly outside the room
- Use of a video laryngoscope is preferred over direct laryngoscopy
- Intubating equipment immediately available: intubating supraglottic airway, Macintosh and Miller blades of appropriate sizes, size 7.0 and 7.5 endotracheal tubes, bougie, scalpel, hemostat
- Medications immediately available:
- Induction meds: etomidate, ketamine or propofol
- Neuromuscular blocker: rocuronium preferred
- Push dose pressors: epinephrine 1 mg or phenylephrine 1 mg diluted in 10 mL syringe
- Norepinephrine infusion in case peri-operative hypotension develops
- Best options for ventilator analgesia and sedation: fentanyl, ketamine and/or propofol
- Pre-intubation oxygenation
- Use a bag-valve mask device attached to a facemask with a tight seal and attached HEPA filter in a spontaneously breathing patient
- Apneic oxygenation
- Recommend bag-mask ventilation with a well-sealed face mask and attached HEPA filter when hypoxia is present or imminent
- High-flow nasal cannula is an alternative
- Complete paralysis should be obtained prior to attempted intubation using video laryngoscope
- If intubation unsuccessful, place a supraglottic airway (SGA)
- Ideally an intubating SGA is placed
- Once stabilized, intubation through the SGA can be performed
- Awake tracheal intubation
- Usually not an option secondary to severe hypoxemia and the time necessary for topical anesthesia and fiberoptic intubation
- Scalpel-bougie cricothyroidotomy for emergency surgical airway
- Use 6.0 endotracheal intubation
- Endotracheal tube exchange
- Indicated for cuff rupture
- Use an airway exchange catheter
- video laryngoscope recommended to observe passage of the new endotracheal tube
- Extubation
- Risk as an aerosolizing procedure
- Complications include stridor from laryngeal edema and laryngospasm
- Have dexamethasone available for post-extubation stridor
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