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APRIL 07, 2020 -- In March 2020, the Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) Airway Research Group and the European Airway Management Society released coronavirus disease 2019 (COVID-19) recommendations that included guidance on airway management and tracheal intubation.
Perform airway management procedures electively rather than as an emergency, employing any means required to maximize first-pass success.
Carry out procedures in a negative pressure chamber (if available) or an isolation area that is equipped with a replenished, complete, and checked emergency airway trolley.
Strict monitoring of entry and departure of staff from the immediate clinical area is necessary, with restriction of personnel to whoever is required.
Through thorough airway evaluation, clinicians should determine whether it is safe to employ asleep tracheal intubation, rather than awake tracheal intubation (ATI).
The use of ATI requires careful consideration owing to the fact that it is potentially a highly aerosol-generating procedure.
Effective pre-oxygenation is mandatory in patients with COVID-19 owing to their risk of rapid arterial oxygen desaturation.
Following preemptive optimization and correction of hemodynamic disturbances, perform pre-oxygenation with a fraction of inspired oxygen of 1.0 for at least 3 minutes at tidal volume breathing or eight vital capacity breaths.
Rapid sequence intubation, indicated for all cases to minimize the apnea time, can result in significant aerosolization with facemask ventilation. Therefore, facemask ventilation should only be performed gently should critical arterial oxygen desaturation occur.
Unless otherwise indicated, cricoid force should not be performed, so that first-pass success can be maximized and optimal ventilation (if needed) is not compromised.
Apneic oxygenation is recommended to prevent desaturation, with low-flow nasal oxygenation ideally used during tracheal intubation attempts.
Because it is an aerosol-generating technique, high-flow nasal oxygen should be avoided.
It is recommended that general anesthetic agents be administered, cautiously, to minimize hemodynamic instability, and that rocuronium 1.2 mg/kg or suxamethonium 1 mg/kg be provided to ensure rapid onset of neuromuscular blockade, maximize first-pass success, and prevent coughing and associated aerosolization.
It is advisable to perform neuromuscular monitoring.
Employment of a videolaryngoscope, ideally disposable but with a separate screen to minimize patient contact, is strongly recommended.Should tracheal intubation fail, gentle manual ventilation may be used, with a maximum of two attempts at tracheal intubation subsequently employed (with consideration of position change, device, and technique between attempts).
Should tracheal intubation fail twice, or if a rescue airway is needed, it is strongly advised that a second-generation supraglottic device, preferably one that permits flexible bronchoscopic intubation, be used.
Consider an early emergency front-of-neck airway (surgical or percutaneous cricothyroidotomy) before a “cannot intubate, cannot oxygenate” scenario independently of critical arterial oxygen desaturation.
An experienced operator should perform an indicated ATI; employment of intravenous sedation may minimize coughing.
Minimize aerosol or vaporized local anesthesia delivery, and consider using mucosal atomizers, swabs, and tampons, as well as (if clinical expertise permits) nerve blocks.
To reduce the risk of cross-contamination, employ single-use flexible bronchoscopes; a separate screen is strongly advised.
Because it is faster than flexible bronchoscopy, ATI with videolaryngoscopy can be considered.
Despite the potential for aerosolization, tracheostomy with local anaesthesia must be considered in the event of a failed ATI.
In the event of a “cannot intubate, cannot oxygenate” scenario, carry out an emergency front-of-neck airway.
If emergency tracheal intubation is required for a COVID-19 patient, personal protective equipment (PPE) must be donned by team members prior to airway management. Gentle facemask ventilation may be required in a hypoxic patient to give more time to the patient and clinicians.
Place high-efficiency particulate air filters between the primary airway device and the breathing circuit, including the expiratory limb of the circuit once the patient is connected to the ventilator.
Unnecessary respiratory circuit disconnections should be avoided, in order to prevent viral dispersion. If disconnection is required, optimize patient sedation to prevent coughing, turn the ventilator to stand-by mode, and clamp the tracheal tube.