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

Read all articles in Emergency Procedures, Endotracheal Intubation, Featured, Glidescope Intubation, King Tube, Laryngeal Mask Airway, Mechanical Ventilation
Tags: awake intubation, COVID-19, difficult airway management, Difficult Intubation, endotracheal intubation, featured, HPC updates, intubation, video laryngoscopy

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