Airway Management in the COVID-19 Era

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 (osmag.net/n7JbED) 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.

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.

Personal protection is the foundation for all healthcare providers involved in airway management. Anesthesia providers should wear disposable surgical caps, fluid-resistant long-sleeved gowns, goggles, N95 masks, disposable face shields and two pairs of gloves. ?Double-gloving allows providers to remove the outer glove to sheath the laryngoscope blade after the airway is secured. Many providers prefer cloth caps, but when caring for suspected COVID-19 patients, disposable caps are the best way to prevent the harboring and transmitting of the virus among staff and patients.

Anesthesia providers are at a higher risk of being exposed to aerosolized droplets of COVID-19, but all members of the surgical team should have access to necessary PPE during intubations. They should wear N95 masks for suspected COVID-19 cases and for asymptomatic open airway cases. A powered air-purifying respirator (PAPR) may also be warranted.

Your facility should have a protocol for the appropriate donning and doffing of PPE that corresponds to your patient population and the procedures being performed. Have your staff review and practice the PPE donning protocol with a colleague, so they can make sure they're doing the right things in the right order, and aren't missing minor but critical steps.

Hand washing is one of the most important steps in preventing the transmission of any infectious disease. There are challenges surrounding hand hygiene during the process of administering anesthesia and airway manipulation, particularly because it involves virus aerosolization. Therefore, anesthesia providers are at a higher risk for being exposed to COVID-19 and need to be extra diligent about treating their hands after every case. Be sure to audit providers' adherence to your facility's hand hygiene policy. Also follow strict environmental cleaning and disinfection procedures in and around the anesthesia workstation. ?Dispose of all used airway equipment in a double-zip-locked plastic bag for proper decontamination and disinfection. The burden is on your facility to have clearly defined environmental cleaning and disinfection policies in place, and to ensure anesthesia providers follow them consistently.

Allocate ORs specifically for patients with confirmed or suspected COVID-19. Also, these patients should not be brought to preop or recovery areas. If you have the opportunity to segregate patients with COVID-19, that's your best and safest option. Of course, this depends on location. In communities with high viral spread, providers should assume every patient is positive unless they present a negative test. In communities where viral spread is less severe, you can be slightly more relaxed. This recommendation is meant to be tailored to a facility's current patient population and exposure to the virus. Availability to COVID-19 testing will ultimately dictate the way your facility handles OR allocation.

COVID-19 highlighted the risk that providers who engage in airway management face on a regular basis and has also drawn much-needed attention to the need for clearer, evidence-based infection control policies and procedures in this area. Prior to the pandemic, I don't think airway experts did the best job at addressing infection control practices during airway management. The pandemic has provided that chance. It's time to take advantage of it. OSM