A Practical Guide for Anesthesia Providers on the Management of Coronavirus Disease 2019 Patients in the Acute Care Hospital : Anesthesia & Analgesia

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COVID-19 Articles: Special Article

A Practical Guide for Anesthesia Providers on the Management of Coronavirus Disease 2019 Patients in the Acute Care Hospital

Abola, Ramon E. MD*; Schwartz, Jonathan A. MD*; Forrester, Joseph D. MD, MSc; Gan, Tong J. MD, MBA, MHS*

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Anesthesia & Analgesia 132(3):p 594-604, March 2021. | DOI: 10.1213/ANE.0000000000005295
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In 2019, Wuhan, China, reported the outbreak of a novel coronavirus associated with severe viral pneumonia.1 The virus, which has been named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), proceeded to cause a worldwide pandemic with 31 million infections and 962,000 deaths as of September 21, 2020.2 Health care workers were confronted with unprecedented challenges. These included expanding patient capacity in acute care hospitals, limitations to personal protective equipment (PPE), and daily changes to recommended safety protocols. This review will provide a framework and key principles for anesthesiologists to prepare for coronavirus disease 2019 (COVID-19) or any future pandemic. Our discussion focuses on 2 areas where the anesthesiologist will be a key member of the health care team: the operating room and the airway team. These principles will enable anesthesiologists to operationalize and incorporate recommendations from government health departments into local hospital procedures. This discussion draws from up-to-date information from the medical literature, informal communications with other hospitals with a high concentration of COVID-19 cases, and our experiences with the COVID-19 pandemic. Stony Brook University Hospital is a 585-bed tertiary care center in Suffolk County on Long Island, which is part of the New York City metropolitan area. Long Island was considered an endemic area for COVID-19 with >46,000 COVID-19–positive patients on September 21, 2020.3

COVID-19 Testing

Testing of COVID-19 patients is key to protect the patient, protect the operating room staff, and allow for proper allocation of PPE. Currently, nasopharyngeal polymerase chain reaction (PCR) serves as the most widespread diagnostic technique and has been considered a “gold standard” for diagnosis despite the lack of a clear-cut definition for a worldwide gold standard.4 Numerous companies have developed PCR technologies and protocols to accommodate the surge in testing demand that still await a rigorous and structured assessment of test sensitivity and specificity by the US Food and Drug Administration.5 Sensitivity estimates across various PCR manufacturers may overestimate the true value associated with nasopharyngeal samples if the manufacturer uses only known positive samples or contrived positive samples.5 False negatives may occur if nasopharyngeal swabs miss infectious material or if there is intermittent viral shedding during the onset of symptoms.6

Estimates of PCR sensitivity vary widely, with 1 systematic review reporting a range from 71% to 98% while a meta-analysis found a pooled sensitivity of 89%.7,8 Another study examining PCR sensitivity in respiratory samples by other routes found a sensitivity of 93% with bronchoalveolar lavage, 72% for sputum, 63% for nasopharyngeal swabs, and 32% with oropharyngeal swabbing.9 Specificity of PCR was assumed to exceed 99% as a gold standard comparator in 1 study, but only 95% in another study.7,8 However, the predictive value of the test depends on more than just sensitivity and specificity. Disease prevalence and pretest probability impact predictive values—as disease prevalence or pretest probability increases, negative predictive value decreases, while positive predictive value increases.

Antibody testing assists with the diagnosis of past SARS-CoV-2 infection via Immunoglobulin M (IgM) and Immunoglobulin G (IgG) antibodies that reach detectable limits roughly 4–5 days after infection. At 8–14 days after infection, 70% of asymptomatic patients will mount detectable IgG, and after 11–14 days, 90% of asymptomatic patients will mount a detectable IgG. Several weeks out from infection, IgG reactivity is thought to exceed 98%.10–12

Health care workers remain at high risk for SARS-CoV-2 infection, with an estimated prevalence ranging from 6% to 7%.13,14 The idea of routinely testing health care staff has emerged as PCR testing capacity continues to grow. At this time, the US Centers for Disease Control (CDC) has offered a framework to monitor health care workers at risk for exposure in a health care facility or in the community.15 High-risk exposures include close contact with a COVID-19–infected individual, provision of direct care to a COVID-19 patient without appropriate PPE or hand hygiene, or contact with COVID-19 secretions without proper PPE or hand hygiene. Health care staff with a high-risk exposure require work restriction for 14 days with active monitoring via daily communication between the staff and health care facility. SARS-CoV-2 testing may be obtained if fever or other concerning symptoms develop in that timeframe but should not impact the 14-day work restriction if the result is negative. Low-risk exposures to essential staff necessitate self-monitoring, and staff may continue to work unless a new fever or other suspicious symptoms arise that prompts SARS-CoV-2 testing. Consequently, routine screening of staff with SARS-CoV-2 PCR could result in either false negatives if conducted too early in the incubation period or lead to a false positive if conducted too frequently and impose workforce strain. Depending on state and local guidelines, routine testing may not have a significant impact on the return to work guidelines for essential health care staff.

Serologic testing is not recommended at this time by the CDC for use with return-to-work decisions or for decisions to spare PPE use in antibody-positive staff.16 Additionally, health care workers who have a positive antibody result without recent illness fitting COVID-19 can continue normal activities with general precautions as the likelihood for an active infection remains low. Consequently, routine antibody testing of staff is not supported via the CDC recommendations. Testing for SARS-CoV-2 in health care staff should be triggered by the presence of a fever or symptoms in the context of active or self-monitoring.

Figure 1.:
Stony Brook Medicine COVID-19 operating room guidelines. COVID-19 indicates coronavirus disease; ENT, ear, nose, and throat; ETT, endotracheal tube; GI, gastrointestinal; HEPA, high-efficiency particular air; PAPR, powered air-purifying respirator; PPE, personal protective equipment; PUI, person under investigation.

If possible, we recommend that all patients be tested for SARs-CoV-2 before urgent surgery, especially in areas with high rates of community infection.17 Symptom screening or screening for exposure to COVID-19 contacts is another strategy that can be used if testing capabilities are limited and the level of community infection is lower.18 Delay of surgery can be considered for patients who are tested positive. If surgery cannot be delayed, utilization of appropriate PPE by the operating room team will decrease the risk of viral transmission. Patients infected with COVID-19 undergoing elective surgery have had poor outcomes. Of 34 asymptomatic COVID-19 patients in Wuhan, China, who underwent surgery, 44% required intensive care unit (ICU) care, and the mortality rate was 20%.19 In Italy, patients with COVID-19 had a significant higher 30 days mortality (odds ratio [OR] = 9.5) with higher pulmonary complications (OR = 35.6) and thrombotic complications (OR = 13.2).20 A larger international, multicenter, cohort study analyzed patients undergoing surgery who had SARS-CoV-2 infection confirmed 7 days before or 30 days after surgery. The 30-day mortality of the cohort was 23.8%. Pulmonary complications occurred in 51.2% of these patients, and the 30-day mortality was 38% in patients with pulmonary complications.21 These principles were incorporated into the Stony Brook Medicine COVID-19 operating room guidelines (Figure 1). In the absence of COVID-19 testing, especially in an area with high community infection, hospitals can consider using precautions against COVID-19 for all surgical patients. This must be balanced against the limitations of a hospital’s PPE supply.

Management of Elective Surgery

Cancellation of elective procedures and surgery is a strategy that can be used to protect patients, preserve PPE and ventilators, and provide manpower (nurses, physicians) for increased hospital and ICU capacity for COVID-19 patients. However, in a retrospective review of New York State ICU admissions between 2011 and 2015, elective surgery accounted for 13% of ICU admissions and 6.4% of ventilator utilization.22 Cancellation of elective surgery was recommended by the US government, as well as several state health departments, early in the pandemic.23 A tiered approach can be used where the types and number of surgical cases can be balanced against the number of COVID-19 infections. The Centers for Medicare and Medicaid Services had defined 3 tiers for surgery—tier 1: low acuity surgery (ie, carpal tunnel release, cataracts), tier 2: intermediate acuity surgery (low-risk cancer, nonurgent spine, and ortho), and tier 3: high acuity surgery (most cancers, neurosurgery, highly symptomatic patients including intractable pain, transplant, and trauma).24 Tier 1 surgeries should be postponed as part of COVID-19 preparations, and tier 3 surgeries should not be postponed. This tier system also can be utilized when hospitals have passed the peak of COVID-19 infections and are restarting elective surgery.

PPE General Precautions

Patients who are positive for SARS-CoV-2 may be asymptomatic when presenting for surgery. Fifty-seven percent of SARS-CoV-2–positive residents at long-term nursing facility and 18% of the SARS-CoV-2–positive passengers on the cruise ship Diamond Princess did not have symptoms on the day of testing.25,26 Therefore screening patients for symptoms of COVID-19 to guide recommendations for PPE may not be useful. Because of these concerns, in our hospital, all operating room staff use at least an N95 respirator with all surgical patients when an aerosol-generating procedure is involved. A surgical mask is worn over the N95 respiratory to allow for N95 reuse or extended use. Although COVID-19 testing can be utilized to triage the use of PPE, hospitals in areas of moderate to substantial community transmission are more likely to encounter asymptomatic or presymptomatic patients. The CDC and the Joint Commission recommend the use of eye protection and an N95 respirator for all aerosol-generating procedures or surgical procedures that might pose higher risk of transmission if the patient has COVID-19, even if a patient has a negative test for COVID-19 due to the risk of false-negatives.27,28 An N95 respiratory may be omitted when a COVID-19–negative patient is undergoing surgery under regional anesthesia or with monitored anesthesia care sedation. Alternatively, operating room staff may leave during intubation and extubation and return to the operating room after a period of time based on the number of air exchanges.17 When routine preoperative COVID-19 testing was not available to triage the use of PPE, our hospital utilized precautions against COVID-19 with all surgical patients. When routine COVID-19 testing is available, and especially in areas with low community infection, testing can be utilized to identify when to use regular surgical precautions versus higher levels of PPE. N95 respiratory supply certainly is a concern, and strategies for N95 extension are discussed later.

COVID-19 Patients or Persons Under Investigation for COVID-19

When a COVID-19 patient or person under investigation (PUI) is scheduled for surgery, PPE can be prepared and ready for operating room staff before the patient’s arrival to the operating room suite. Operating room staff should use an N95 respiratory, surgical mask over N95 to allow for reuse/extended use, eye protection, gloves, and an isolation gown. These recommendations follow the World Health Organization (WHO) and CDC recommendations for aerosol-generating procedures performed on COVID-19 patients.29 KN95 respirators, manufactured in China, performed similarly to an N95 respiratory by 3M Personal Safety Division.30 The US FDA have concluded that the KN95 respirator, if authentic, is appropriate to protect the public.31

Isolation of COVID-19–positive or PUI patients from noninfected patients can limit nosocomial spread of infection. Strategies to achieve this include providing a separate route for entrance to the operating room for COVID-19/PUI patients and designating specific operating rooms for these patients.32 Isolating these patients to specific operating rooms can potentially decrease transmission to noninfected patients. Operating staff should use PPE precautions appropriate for a COVID-19/PUI patient when working in these operating rooms.

Operating rooms are built as positive pressure environments to decrease the risk of surgical site infection. If possible, for certain surgeries (such as ear, nose, and throat [ENT] procedures or tracheostomy), reversal of airflow in the operating room will allow these designated operating rooms to be negative pressure and limit the potential for spread of COVID-19 from this room.33 However, the availability of negative pressure operating rooms may be limited. COVID-19 or PUI patients can recover in the operating room or in a negative pressure isolation room in the postanesthesia care unit.

N95 Conservation Strategies

Figure 2.:
Strategies for PPE sourcing. Adapted from Livingston et al.34 HVAC indicates heating, ventilation and cooling; IV, intravenous; PPE, personal protective equipment.

The COVID-19 crisis has placed N95 mask supply shortages front and center to public attention. A wide range of strategies to conserve masks have been proposed, many of which are shown in Figure 2 adapted from recommendations in a recent editorial.34 Generally, extended use of a mask is preferred over reuse to reduce the risk of self-contamination from repeated donning and doffing of the same equipment.35 Should reuse of the N95 be required, then utilizing a full face shield and facemask over the N95 will limit contamination of the reusable mask.35 Placement of an N95 into a paper bag for storage is preferred when reusing the mask since viral half-life on paper bag surfaces may be shorter than plastic bags. Following extended use or reuse, N95 masks may be decontaminated via ultraviolet light, vaporized hydrogen peroxide, and hot air (75 °C, 30 minutes, 20 cycles). Grouping COVID-19 patients together in a unit, potentially as an openly contaminated unit, may permit extended use of PPE further.35

Powered Air-Purifying Respirator

A powered air-purifying respirator (PAPR) can be worn for high-risk aerosol-generating procedures instead of an N95 respirator in individuals who have facial hair or an N95 respirator does not fit. A PAPR (Figure 3) consists of a head top or hood attached to a battery-powered blower that passes contaminated air through a high-efficiency particular air (HEPA) filter to provide the individual with purified air.36 The PAPR can be checked using an airflow indicator meter with a floating ball placed on the air hose to ensure adequate airflow through the filter.

Figure 3.:
PAPR. Diagram of PAPR from Occupational Safety and Health Administration (osha.gov). Anesthesia resident demonstrating the use of the PAPR as part of our airway team. PAPR indicates powered air-purifying respirator.

The PAPR may provide added protection over the N95 respirator. Ten percent of N95 respiratory users encountered breakthroughs with exposure to the influenza virus compared to full protection provided by a PAPR.37 Following the SARS pandemic in 2003, 3 health care workers out of 33 who performed intubation on SARS patients acquired SARS. Two of these health care workers reported the routine use of an N95 respirator.38 Because PAPR incorporates a face shield and hood, individuals are less likely to accidentally contaminate their face. The Association of Operating Room Nursing (AORN) has stated that providers who are unable to be fit tested for an N95 may use a PAPR in the operating room. AORN recommends multidisciplinary review by infection control, nursing, surgery, and anesthesia to determine how PAPRs may be safely used for respiratory protection in the perioperative environment when a sterile field is present. Studies have demonstrated that PAPRs do not cause micro-organism to flow onto sterile fields.39

The cost and available supply of PAPRs limit their availability for use for respiratory protection. The availability of a PAPR is one limitation of this device. Another drawback of the PAPR is that it is multiuse, and the process of doffing and decontaminating the PAPR is a potential risk for viral transmission. Mishandling PPE was identified as a potential source of contamination of the PAPR hood, with clinicians squeezing of the front face shield, fumbling with PAPR hood ties, and PAPR hood shroud contacting exposed arms. Cleaning, decontamination, and drying are recommended before reuse of the PAPR hood.

Aerosolizing Procedures and Tracheostomy

Surgeries are classified as high risk if they had been associated with a high rate of viral aerosolization. These surgeries include ENT, nasopharynx, oropharynx, trachea, and lung procedures. Bronchoscopy and endoscopy of the gastrointestinal (GI) tract are both considered high-risk aerosol-generating procedures.40 These types of procedures in COVID-19–positive patients are considered the “highest risk” for viral transmission to health care workers. In our hospital, all patients presenting for these types of surgeries underwent COVID-19 testing before surgery. If a patient was COVID-19 positive, the delay of surgery was strongly recommended. If the delay was not possible, the operating room staff were instructed to, at a minimum, use PPE with N95 respirators, eye protection, isolation gown, and gloves. However, if available, the use of a PAPR hood for all operating room staff in COVID-19 patients undergoing these “high-risk” surgeries may further protect the health care staff. As an example, COVID-19 patients undergoing tracheostomy were performed in a negative pressure operating room with the use of a PAPR hood by all operating room staff members. Concerns have been raised about the use of a PAPR hood contaminating a sterile surgical field; therefore, the risks and benefits of the use of a PAPR need to be weighed against the risk of surgical site infection.41

COVID-19 has challenged the routine benefits of tracheostomy, such as decreased sedative requirements, improved pulmonary toilet, and decreased ventilator-associated pneumonia with the high risk for disease transmission due to aerosol generation during tracheotomy.42 Appropriate timing of tracheostomy placement in candidate patients may help maximize the benefits of the procedure over risk to health care providers. Current recommendations for considering tracheostomy placement range from 14 to 21 days of intubation after acute viral shedding is expected subside.42,43 Although tracheal stenosis may remain a concern for prolonged orotracheal intubation, severe symptomatic tracheal stenosis occurs <1%–2% of cases with low-pressure cuffs.43 At the authors’ institution, tracheostomy candidates were required to have appropriate ventilator requirements and a reasonable prognosis expected following tracheostomy. The Stony Brook tracheostomy criteria included minimal oxygen requirements with a PEEP ≤8 cm H2O and fraction of inspired oxygen (Fio2) ≤50%, maximum single-organ failure beyond the lungs, and expected survival for at least 1 year before tracheostomy consultation proceeds further for individualized review.

Either open or percutaneous dilational tracheostomy (PDT) placement may be pursued according to the proceduralist’s preference. Use of an open technique may reduce aerosolization risk compared to PDT placement. If anatomically feasible, a blind technique may be used to minimize aerosol risks associated with bronchoscopy at the cost of a higher complication rate.42,43 Disposable equipment is preferred independent of the technique.44

Bedside tracheostomy placement in the ICU offers the benefits of minimizing patient transport and potentially utilizing negative pressure isolation rooms. However, bedside tracheostomy may be associated with suboptimal equipment, lighting, patient positioning, and restricted ability of the assistants.45 Independent of location, keeping procedural teams to a minimal number of highly experienced personnel is preferred.42 Simulation sessions during tracheostomy team training and preparation may improve practice workflow and thereby potentially reduce procedure time and viral exposure. Communication tools, such as radio headsets and whiteboards, can be utilized as a part of a closed-loop communication strategy.44 At our institution, a PAPR was utilized for tracheostomy placement. In the case that a PAPR would not have been available in a reasonable timeframe, then a properly fitted N95 mask with closed eye protection and a face shield could be utilized.42

Anesthesia Considerations

Intubation and extubation of the trachea are both considered aerosol-generating procedures and are routinely performed by anesthesiologists. At our institution, anesthesia providers use an N95 respirator with a surgical mask at a minimum during intubation for all patients. During intubation, the number of personnel in the operating room is limited to those participating in the intubation. With an operating room with 15 air exchanges, 99% of air particles have been exchanged after 18 minutes, and 99.9% of air particles have been exchanged after 28 minutes.46 Although there are limited data about the best way to intubate a COVID-19 patient, the use of video laryngoscope has been suggested for greater intubation success, and this provides a greater distance between the anesthesiologist and the patient compared to direct laryngoscopy.32 Rapid sequence induction (RSI) and avoidance of bag-mask ventilations are interventions that can decrease the generation of respiratory aerosols.32 A PAPR hood can be used during intubation if available, especially in COVID-19–positive patients. A HEPA filter attached to the endotracheal tube can protect the operating room staff and prevent viral contamination of the anesthesia machine. A “high-quality” heat and moisture exchange filter (HMEF) can be utilized, which has the advantage of preserving humidification. Heat and moisture exchange (HME) without a filter will provide no protection.47 Intubation in a negative pressure room is another strategy to limit viral transmission, but this would require transport of a recently anesthetized patient to another location with positive pressure.

Strategies to reduce viral transmission during the maintenance and emergence of anesthesia were used at our institution.48 The use of short-acting anesthetics and minimization of opioids during surgery allowed for a faster emergence from anesthesia, facilitating less airway interventions (ie, jaw thrust, oropharyngeal airway placement) after extubation. When an anesthesia mask was no longer required, a surgical mask was placed on the patient. Minimizing personnel in the operating room during extubation was another strategy to protect operating room staff. At our institution, patients infected with COVID-19 recovered from anesthesia in a respiratory isolation room either in the PACU or on the inpatient ward. They were cohorted away from patients who are not infected with COVID-19. When patients infected with COVID-19 were being transferred to the ICU, a tight-fitting surgical mask was placed on the recently extubated patient, or a HEPA filter was attached to the endotracheal tube if the patient was still intubated. Anesthesia and transport staff used PPE appropriate for respiratory protection during ICU transport.

Intubation Boxes

Figure 4.:
Example of an intubation box from Aerosol Box.49

The open-source Aerosol Box has been proposed as an innovative tool to protect health care providers during aerosolizing procedures, especially those providers with limited access to a PAPR (Figure 4). The box is constructed from 4 pieces of acrylic or polycarbonate for an estimated cost of US $67.49 One study tested the efficacy of the aerosol box in a mannequin-based study of fluorescent dye contamination from simulated coughing during intubation. Using the aerosol box provided complete protection from fluorescent droplet contamination, whereas absence of the box exposed the health care provider to complete droplet contamination of his or her face shield.50 Microscopic aerosol contaminants were not investigated in the study. The findings from the simulation further support the potential use of the box when PPE supply is significantly reduced. However, the simulation noted that the box might restrict hand movement during airway manipulation. Training with the device is recommended, with a plan to remove the box when airway management proves difficult. Limitations on body habitus the box fits, the crowded workspace within the box, and bulky composition may impose additional challenges to routine aerosol box use.51

Restarting Elective Surgery

There are several challenges that an anesthesia department will confront when restarting elective surgery. A hospital must ensure that they have met state or government regulatory requirements before restarting elective surgery. These generally ensure that a hospital has an adequate supply of PPE, patient beds, ICU beds, and health care staff with provisions to accommodate the second wave of COVID-19 infections.52 Operating room nursing and physician staff may have been redeployed to COVID-19 units, and this may limit the number of operations that can be performed. The number of surgeries will also depend on the number of hospital beds and ICU beds available for postoperative care. Urgent procedures generally will have priority over elective procedures. Surgical departments can stagger the number of cases that will require ICU and prolonged hospital postoperative care.

A major challenge will be a plan for COVID-19 screening or COVID-19 testing for presurgical patients. COVID-19 testing ensures the safety of the patients as patients with COVID-19 undergoing elective surgery were found to have poor outcomes.19 If a patient tests positive for COVID-19, delaying a patient’s surgery may be prudent. It is currently unknown as to when it is appropriate to proceed with surgery in a patient who has previously tested positive for COVID-19. The answer likely depends on the patient’s illness severity. Their current functional status after COVID-19 infection may provide some insight into their cardiopulmonary reserve and their appropriateness for elective/urgent surgery. A patient is considered noninfectious according to the CDC guidelines when they have tested negative for COVID-19 twice greater than 24 hours apart (test-based strategy), or 10 days after illness onset with at least 3 days without symptoms (symptom-based strategy).53

Key Concepts

COVID-19 testing will allow for the appropriate allocation of PPE resources. Aerosol-generating procedures, such as intubation, extubation, and tracheostomy, are high risk for viral transmission, and we recommended that operating room staff utilize higher levels of PPE. For aerosol-generating procedures in COVID-19–positive patients, at a minimum, level 3 PPE, including N95 respirator, eye protection, isolation gown, and gloves, will decrease the risk of viral transmission. A PAPR in this situation will afford greater protection than the N95. Universal level 3 PPE precautions can be utilized in settings where there is a lack of COVID-19 testing and high community incidence of infection, but this must be balanced by resource availability. Challenges that hospitals will face in restarting elective surgery include ensuring adequate hospital resources (PPE, hospital beds, staff) and a plan for COVID-19 screening or testing in all surgical patients.

Airway Teams

COVID-19 has challenged the world’s health care system by precipitating a once-unimaginable incidence of respiratory failure requiring invasive mechanical ventilation. Anesthesiologists will inevitably find themselves at the frontlines intubating patients within the hospital.54 These airway teams operate around the clock and remain protected from operating room coverage responsibilities. Essential to the development of an effective COVID-19 airway team are a robust planning of staffing, best practices, protocols, equipment, and ongoing quality improvement that all recognize the unique challenges posed by COVID-19.

The successful emergence of such airway teams has already been described in Chinese hospitals to cope with the wave of intubations.55 The team consisted of 4–18 anesthesiologists with only 1–2 team members rotating in shifts covering isolation wards to limit provider exposure risk. Dedicated intubation carts remained inside the isolation ward with prepacked intubation kits serving to limit supply traffic between the patient rooms. The intubation cart consists of advanced airway management tools, including a light wand, supraglottic airway, bronchoscope, and cricothyroidotomy kit.55 A practical example of an airway team at our institution is discussed in Supplemental Digital Content, Appendix 1, https://links.lww.com/AA/D263.

Staffing Considerations

COVID-19 poses some unique challenges to staffing an airway team. As intubation constitutes an aerosolizing procedure that increases the occupational risk for disease transmission, our airway teams limited time managing the airway to a minimum. At our institution, airway teams consisted of at least 1 highly experienced anesthesia provider to perform the intubations to limit exposure time and decrease the likelihood of failed attempts requiring rescue mask ventilation.56,57 Our airway teams had another anesthesia provider that could assist with medication administration, monitoring, and difficult airway management. Having 2 anesthesia providers on a team also provided a means for assisting each other during donning and doffing of PPE. High intubation rates, coupled with the physical and mental challenges imposed by PPE, likely placed airway team members at risk for significant fatigue. Shift length for airway teams was kept to an appropriate length to ensure that provider fatigue does not impair procedural performance. A small group of anesthesia providers served as a backup on-call pool in case assigned airway team members contract COVID-19 and cannot provide patient care. Airway team members performed regular surveillance for onset of viral symptoms.58

Considerations for Safe Conduct of Endotracheal Intubation

Limiting aerosolization of airway secretions in COVID-19 patients has prompted the recommendation for routine use of RSI with video laryngoscopy during intubation.56,57,59,60 An RSI technique achieves multiple goals in critically ill COVID-19 patients, including decreased coughing, decreased mask ventilation use, and mitigating aspiration risk, compared to routine induction technique.58,61 Sufficient muscle relaxation must be employed, and lidocaine may serve as a useful adjunct to further mitigate patient coughing during the induction process.58,62 Application of 2 layers of wet gauze covering the patient’s mouth and nose has been proposed to trap secretions during preoxygenation or during unplanned mask ventilation.58 Covering the patient’s lower face with a towel may alternatively help limit the dispersion of aerosolized secretions during preoxygenation. Patients may also present with support from noninvasive positive pressure ventilation (NIPPV), such as bilevel positive airway pressure (BIPAP) or high-flow nasal cannula (HFNC), which pose a higher exposure risk to anesthesia providers but may be utilized for preoxygenation.63,64

Video laryngoscopy with a disposable blade is a recommended first-line technique in patients who are candidates for an RSI to reduce laryngoscope contamination.56,58 If a reusable laryngoscope is utilized, an ample supply of devices and preparation to disinfect the device with ethylene oxide or hydrogen peroxide plasma is recommended.58 Studies on the use of video laryngoscopy versus direct laryngoscopy suggest no significant time difference for intubation rates, though a recent study on routine video laryngoscopy use in elective surgeries suggested a higher first-pass success rate with less complications.65–67 Our airway teams had direct laryngoscopy backup readily available as COVID-19 patients will have rapid desaturation, and bag-mask ventilation may not be effective. The COVID-19 patient with a difficult airway is a particularly challenging circumstance where the speed of intubation with video or direct laryngoscopy needs to be weighed against the need for fiberoptic intubation. Awake intubation can be considered in certain COVID-19 patients to avoid severe hemodynamic compromise that may occur with anesthesia induction.


The COVID-19 pandemic has brought many challenges to hospitals around the world. Hospital guidelines, protocols, and PPE recommendations ensure the safety of health care workers. Anesthesiologists have been enlisted in airway and intubation teams. Appropriate protocols for these airway teams facilitate successful intubations in our critically ill COVID-19 patients while protecting the health and safety of our anesthesia providers. An understanding of these challenges will allow anesthesiologists to develop procedures and practices within their hospitals for COVID-19 patients.


Name: Ramon E. Abola, MD.

Contribution: This author helped write the manuscript and edit for critical content.

Name: Jonathan A. Schwartz, MD.

Contribution: This author helped write the manuscript and edit for critical content.

Name: Joseph D. Forrester, MD, MSc.

Contribution: This author helped write the manuscript and edit for critical content.

Name: Tong J. Gan, MD, MBA, MHS.

Contribution: This author helped write the manuscript and edit for critical content.

This manuscript was handled by: Jean-Francois Pittet, MD.


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