Table 1.
Airway management and related procedures in critically ill COVID-19 patients: A summary of recommendations
| 1. | Environment |
| We recommend that all COVID-19 patients should be treated in negative pressure rooms. | |
| We recommend that a minimum of 12 air exchanges per hour should be maintained to dissipate aerosols. | |
| We recommend against the practice of using dedicated rooms for airway procedure. | |
| 2. | Personal protective equipment (PPE) |
| We recommend that all aerosol-generating procedures should be performed with full PPE. | |
| We recommend the use of PAPRs over N95 respirators for aerosol-generating procedures, whenever available. | |
| We recommend using a double pair of gloves for all aerosol-generating procedures. | |
| 3. | Airway management team of HCWs |
| We recommend that each ICU should have an airway team, and should have an intensivist or anesthesiologist who is trained in airway management. | |
| We recommend that number of people in the airway team should not exceed three. | |
| We strongly recommend against having HCWs with comorbid conditions, on immunosuppressive therapy, those aged older than 60 years, and pregnant females as part of airway team. | |
| 4. | Disposable vs reusable airway equipment |
| We recommend use of single-use disposable airway equipment. | |
| We strongly recommend laying down of local protocols for transport and disinfection of equipment for institutions using reusable equipment. | |
| 5. | Barrier devices |
| We recommend use of a barrier device for aerosol-generating procedure. | |
| We do not recommend for or against any specific barrier device. We recommend that the team uses the barrier device which it is familiar with. | |
| We recommend removal of barrier device if it makes airway management difficult. | |
| 6. | Preparation: Airway cart |
| We recommend that every intensive care unit should have an airway cart. | |
| We recommend that the airway cart should be inspected by a senior airway manager, using a checklist, during every shift. | |
| 7. | Preparation: Assessment of airway |
| We recommend use of MACOCHA or HEAVEN criteria for predicting difficult airway. | |
| For teams, which are unfamiliar with these criteria, we recommend that they use criteria, which the team is familiar with. | |
| 8. | Preoxygenation |
| We recommend that all patients should be preoxygenated for 3–5 minutes with 100% oxygen. | |
| We recommend a face mask with tight-fitting seal for preoxygenation. | |
| We recommend use of a viral filter between the mask and the respirator. | |
| We recommend against the use of high-flow nasal cannula oxygen or high-flow oxygen with reservoir bags for preoxygenation | |
| We recommend placing an oxygen mask, over HFNC cannula, if the patient is already on HFNC, and stopping HFNC oxygen flow, before removal of mask for intubation. | |
| 9. | Rapid sequence and delayed sequence intubation |
| We recommend rapid sequence intubation for all COVID-19 patients. | |
| In agitated and uncooperative patient, we recommend delayed sequence intubation. | |
| We recommend higher doses of neuromuscular blocking drugs for rapid achievement of neuromuscular paralysis. | |
| 10. | Oxygenation during apnea and manual ventilation |
| We recommend against the use of apneic oxygenation using HFNC and manual ventilation in patients without severe hypoxia. | |
| In patients with severe hypoxia, if manual ventilation is needed, a two-handed C and E approach is recommended to obtain a tight seal with the face mask. | |
| We recommend use of second-generation supraglottic airway with filter for ventilation during apnea, whenever available. | |
| We recommend use of small tidal volumes in patients requiring manual ventilation. | |
| We strongly recommend against use of high-flow nasal oxygenation for apneic oxygenation. | |
| 11. | Conventional vs videolaryngoscopy |
| We recommend the use of videolaryngoscope over conventional laryngoscope for TI. | |
| We do not recommend for or against any specific videolaryngoscope. | |
| We recommend against the use of videolaryngoscopes with integrated oxygen channels. | |
| We recommend against the first time use of videolaryngoscopes in COVID-19 patients if the operator is not experienced in its use. | |
| We recommend the use of bougie with preloaded endotracheal tube for intubation. | |
| 12. | Use of endotracheal tube clamps |
| We recommend use of endotracheal tube clamps. | |
| We recommend that the clamps be removed only after the inflation of endotracheal tube cuff and the endotracheal tube is connected to the ventilator. | |
| 13. | Confirmation of correct placement of endotracheal tube |
| We recommend the use of capnography for confirmation of tube position. | |
| We recommend against auscultation method as only method for confirmation of tube position. | |
| We do not recommend for or against the use of ultrasonography for confirmation of tube position. An experienced person may use it, but capnographic confirmation is a must for all patients. | |
| 14. | Unanticipated difficult intubation |
| We recommend early use of second-generation supraglottic airway for unanticipated difficult airway. | |
| We recommend cricothyroidotomy by a scalpel and bougie technique. | |
| We recommend against the practice of apneic oxygenation during cricothyroidotomy or during bronchoscopy-aided intubation. | |
| We recommend against the use of percutaneous tracheostomy in unanticipated difficult airway, unless expertise is available and this is deemed life-saving. | |
| 15. | Tracheal extubation |
| We recommend the use of barrier device during extubation. | |
| We recommend against the use of T-piece trials to assess readiness for extubation. | |
| We strongly recommend against the practice of inducing cough to assess readiness for extubation. | |
| We recommend against performance of leak test. | |
| We do not recommend for or against the use of sedatives before extubation. | |
| We recommend against use of routine nebulization after extubation. | |
| We recommend the use of surgical facemask over the patient face, immediately after extubation. | |
| 16. | Percutaneous tracheostomy |
| We recommend against use of percutaneous tracheostomy in nonventilated patients. | |
| We recommend the use of sedation and neuromuscular paralysis during tracheostomy. | |
| We recommend ultrasound over bronchoscopy-aided percutaneous tracheostomy to minimize exposure to HCWs. | |
| 17. | Flexible fiberoptic bronchoscopy |
| We recommend against use of bronchoscopy in nonventilated patients for diagnostic purposes. | |
| When indicated, we recommend that endotracheal tube be clamped and ventilation be paused before insertion of bronchoscope. | |
| We recommend for insertion of bronchoscope through suction port of catheter mount over the main channel of catheter mount. | |
| 18. | Nebulization in COVID-19 patients |
| We recommend against the use of routine nebulization in COVID-19 patients. | |
| We recommend for the use pMDI or DPI in spontaneously breathing, cooperative patient. | |
| We recommend against the use of jet nebulizers in patients where pMDI or DPI can be used. | |
| We recommend the use of mouthpiece over mask for nebulization, when jet nebulizer is used. We recommend use of viral filter on the expiratory port of mouthpiece. We recommend use of viral filter on the expiratory port of mouthpiece. | |
| We recommend against the use of jet nebulizer in ventilated patient. | |
| We recommend the use of mesh nebulizer in ventilated patient. | |
| We recommend that the mesh nebulizer be placed at the Y piece, with filter placed between Y-piece and nebulizer. | |
| 19 | Airway suction in ventilated COVID-19 patients |
| We strongly recommend against the use of open suction. | |
| We recommend the use of closed in-line suction device for airway toileting. | |
| 20. | Airway management during cardiopulmonary resuscitation |
| We recommend early use of advanced airway devices during CPR. | |
| We recommend brief interruption in chest compression to secure the airway with an advanced airway device. | |
| We recommend use of ICU ventilators for ventilation during CPR instead of manual ventilation. |