Summary of Difficult Airway Management in COVID-19 Patients

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


Foley LJ et al. Difficult Airway Management in Adult COVID-19 Patients: Statement by the Society of Airway Management. Anesthesia and Analgesia. March 12, 2021 ahead of print

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