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Archive COVID-19 2021

Airway Management in the COVID-19 Era

Anesthesia providers must take additional steps to perform intubations safely and effectively.

Brett Morgan

Brett Morgan, DNP, CRNA


Rebecca Barnett
DRESSED IN LAYERS The pandemic has highlighted the importance of wearing proper protection when intubating patients.

COVID-19 has all healthcare workers on edge — especially those involved in airway management. The coronavirus is found in sputum and upper airway secretions, putting anesthesia providers in a direct pathway of exposure during intubations. Minimizing the risk of transmission during these high-risk procedures requires careful preparation, necessary equipment and experienced anesthesia providers who can troubleshoot unforeseen complications. Adhering to the following recommendations ( issued by the American Association of Nurse Anesthetists will help keep your anesthesia providers and surgical team safe when treating patients who are suspected of having COVID-19.

1. Rely on the experts

Anesthesia professionals within your facility who have the most experience in airway management should perform intubations during cases involving patients with suspected COVID-19. This isn't role-specific. For instance, if nurse anesthetists are the most frequent intubators on your anesthesia team, they should secure airways. This will minimize the time it takes to secure an airway because you should not be bagging a patient during this procedure. The goal is to safely minimize the likelihood of aerosolizing airway content. You want to rely on a provider who is highly experienced, who can intubate quickly and efficiently, and who has the most likelihood of doing it in one attempt.

Additionally, limit the number of staff members present during airway manipulation to reduce the risk of unnecessary exposure. CDC guidelines say only staff who are critical to managing the airway or making sure the procedure runs safely should be in the environment where it's occurring. In many cases, that's only the anesthesia provider who's physically securing the airway. But the provider may require the assistance of a registered nurse. That's OK, but the rest of the OR staff should be out of the environment. It's important that each facility has a clearly defined policy that states who the critical members of the airway management team are, who should be assisting and who should be out of the environment while the intubation is taking place.

2. Minimize aerosolization

Pamela Bevelhymer
SAFE SPACE Video laryngoscopes decrease a provider's exposure to aerosolized COVID-19 particles.

Preoxygenate the patient for five minutes with 100% FiO2 and perform rapid sequence induction (RSI) to avoid manual ventilation of the lungs. Use a video laryngoscope to improve intubation success and avoid awake fiberoptic intubations, whenever possible. Atomized local anesthetic aerosolizes the virus.

These recommendations are critical because certain airway maneuvers that would normally be done on patients prior to the pandemic have the potential to create aerosolized virus particles. Standard anesthesia practices — like bagging the patient— actually increase the risk of the virus being transmitted into the air in droplets. To avoid this, optimize patients' oxygen levels and don't perform unnecessary airway maneuvers until the airway is secure, which video laryngoscopes can significantly expedite.

Video laryngoscopes allow for quicker visualization of the vocal cords and let the anesthesia provider stand further back from the airway because they're referring to a video screen as opposed to looking directly down the patient's airway. Theoretically, a video laryngoscope will decrease the risk of exposure to the anesthesia provider and, in many cases, give them a greater sense of safety.

Place a high-efficiency hydrophobic filter between the face mask and breathing circuit or between the face mask and reservoir bag to avoid contaminating the atmosphere. This is a standard, universally recommended step. But like all standard recommendations, it's also worth reminding your staff — especially with all the additional precautions providers must take in the era of COVID-19. Also, use extra caution whenever a procedure has a high probability of creating aerosolization. For example, if a patient will be breathing spontaneously, place a surgical mask over the oxygen face mask to help control spray.

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