Table 2.

Airway management recommendations and consensus.

First authorDateCountry or Society	PPE	Intubation	Extubation	NIV & HFNC	eFONA & Tracheostomy	Bag Mask Ventilation & SAD	Medication	Key points
Brewster et al. 01.06.20 Australian and New Zealand College of Anesthetists/Safe Airway Society	PPE: minimum: impervious gown, theater hat, N95 mask, face shield, eye protection, double gloves “Buddy system”: guided by specially trained and designated staff member acting as “spotter”	RSI, Indirect VL (video screen) maximizing distance between airway and operator; Macintosh or hyperangulated blade; place the tube to correct depth; inflation of the cuff before positive pressure ventilation; viral filter to end of the tube; cuff pressure monitoring	Face mask ready; 2 staff members with PPE (same as intubation); do not encourage the patient to cough; minimize coughing by the use of intravenous opioids, lidocaine, or dexmedetomidine. Consider plastic sheets in case of coughing, place oxygen mask immediately after; oral suctioning	No evidence Should be assumed that NIV & HFNC are aerosol-generating procedures; airborne isolation rooms; protective PPE (including N95/FFP2 masks)	eFONA (CICO): Scalpel-bougie technique (to minimize the risk of high-pressure oxygen insufflation via a small-bore cannula). No attempts to deliver oxygen from above during procedure (avoid aerosolization) Tracheostomy: N/A	Avoid BMV. If needed: use a vice (V-E) grip; minimize ventilation pressure through ramping and/or early use of an oropharyngeal airway with low gas flows; filter between mask and bag SAD: likely to protect better than BMV	Initial NMB: rocuronium (>1.5 mg/kg IBW) or suxamethonium (1.5 mg/kg TBW). Generous dosing for rapid onset and minimizes the risk of coughing. To avoid coughing during extubation: intravenous opioids, lidocaine or dexmedetomidine	Follow existing guidelines; modify them for COVID-19; early intubation; significant institutional preparation; principles for airway management should be same for all COVID-19 patients; safe, simple, familiar, reliable, and robust practices should be adopted
Wax et al. 12.02.2020 Canada	Fluid-resistant gown, gloves, eye protection, full face shield, fit-tested N95 mask, hair covers or hoods; longer sleeved gloves; consider powered air purifying respirator (PAPR); scrub suits or full coveralls under PPE; hand hygiene after PPE use; remove PPE under supervision of an infection control coach using checklist	VL; RSI; only essential team members; airborne isolation room; end tidalCO2; all exhaled gas from the ventilator should be filtered Rule out Pneumothorax in sudden respiratory deterioration (Ultrasound on bedside)	n/a	No evidence HFNC limited to patients in appropriate airborne isolation. Avoid NIV (CPAP/BiPAP) use outside of appropriate airborne/droplet isolation. Avoid nebulization of medications	n/a	Bag-mask ventilation can generate aerosols (avoid when possible); filter between mask and bag	Use of TIVA for anesthesia, avoid gas	n/a
Cook et al. 17.03.2020 UK/Difficult Airway Society, Association of Anesthetists, the Intensive Care Society, Faculty of Intensive Care Medicine, Royal College of Anesthetists	PPE; mask (FFP3), simple to remove; avoid complex systems; cover the whole upper body; dispose, appropriately immediately after “doffing”. “Buddy system” (observer); checklists; double-gloving for endotracheal intubation; use anti-fog for goggles/eyewear; training and practicing PPE use; negative pressure rooms with good rates of air exchange (>2 times/h)	Specific intubation team (not part of the risk groups); most experienced airway manager; simulation; single-use equipment; rather early than late intubation; limit team to 2 persons performing intubation inside + 1 runner outside), prepare and communicate before intubation; airway strategy (primary plan and the rescue plans) avoid AGPs; good preoxygenation with sealed face mask (3–5 min), RSI, VL; intubation checklists; dedicated intubation trolley, aim to achieve first attempt success; no test of new techniques	Delayed extubation; minimize coughing; appropriate physiotherapy, tracheal and oral suction as normal before extubation; prepare for mask or low flow nasal oxygen delivery before extubation; after extubation, place a facemask; SAD may be considered as a bridge to extubation to minimize coughing; a second procedure and the possibility of airway difficulty, unlikely to be a first-line procedure; use of an airway exchange catheter is relatively contra-indicated; use drugs to suppress coughing	No evidence HFNC recommendation debated: delays intubation, needs much O2 (empty tanks)	Scalpel cricothyroidotomy in CICO situations wearing full PPE; Closed suction	BMV: 2-handed V-E grip SGA: second generation as rescue airway also to improve seal	Intubation: Consider Ketamine 1–2 mg/kg; deep neuromuscular relaxation with rocuronium 1.2 mg/kg IBW or succinylcholine 1.5 mg/kg TBW Extubation: dexmedetomidine, lidocaine, and opioids	Safe, accurate, and swift airway management
Sorbello et al. 27.03.2020 Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva European Airway Management Society	PPE: PAPR, with helmet, protective total body suite, double gloves; If no PAPR available: goggles/face shield, FFP3/2 or N95 mask, waterproof gown, overshoes; Dedicated donning/doffing area	Preoxygenation with or without CPAP and PEEP; RSI technique; Nasal O2 1–3 L/min during apnea; VL (with separate screen) + introducer; second generation SDA if failed intubation; Early cricothyroidotomy if CICO; ATI only if mandatory	n/a	NIV, HFNC should not delay an early elective intubation	Cricothyrotomy in CICO situations	Avoid BMV SADs only as rescue, 2nd generation to intubate through	Rocuronium 1.2 mg/kg IBW or Suxamethonium 1 mg/kg TBW	Full airborne protection for every phase of airway management; Training, planning, anticipation; Maximize first-pass attempt
Patwa et al. 23.05.2020 All India Difficult Airway Association	Hand hygiene Full PPE: waterproof gown, long shoe covers, a cap, goggles, a fit-tested N95 mask, double layer of gloves, and a head hood or full face shield; Correct donning and supervised doffing; covering the patient with a plastic sheet or intubation box.	Preoxygenation with a 2-hands 2 persons technique; continuous capnography (leakage monitoring); Low-flow O2 (<5 L/min) nasal during apnea; RSI; most experienced clinician; Ventilation after cuffing Closed suction system; Consider ATI only in high selected cases with anticipated difficult airway	Same protection as for intubation; Suction only if necessary; Prevent coughing, agitation and emesis; Avoid any manipulation; Defer extubation if there are concerns	NIV and HFNC not recommended	Avoid cannula or needle cricothyrotomy with jet ventilation Surgical cricothyrotomy in case of complete failure of ventilation	Avoid BMV Consider surgery with SAD if safe, or awakening the patient with SAD in place	Suxamethonium or rocuronium for anesthesia induction	Modified AIDAA algorithm for airway management during COVID-19 pandemic
Al Harbi et al. 17.04.2020 Saudi Anesthesia Society	Hand hygiene Disposable N-95 masks, goggles, footwear, water-proof gowns, and gloves (consider double glove technique); PAPR for high-risk AGP.	Intubation by the most experienced clinician; Standard ASA monitoring; VL (single-use blade); Ventilation after inflation of the cuff; Lowest gas flow acceptable	n/a	n/a	n/a	n/a	n/a	Adherence and correct usage of PPE; Ad interim Guideline (COVID pandemic still outbreaking)
Matava et al. 13.04.2020 Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative/Canadian Pediatric Anesthesia Society	Not specified PPEs; teams reduced to the minimum to preserve PPE, importance of correctly donning/doffing PPEs (with coaches). High risk clinicians should not be involved.	RSI, VL; Parents may be present until airway management.	Deep sedation (see medication) to avoid coughing Closed suction system Extubation in the OR	HFNC to be avoided if possible	n/a	Avoid BMV and Mask Induction Consider 2nd generation SADs (good seal, low airway pressures).	Premedication not nasal, oral, or rectal should be preferred Consider dexmedetomidine, TIVA for extubation	Protection of healthcare workers is priority; adapt guidelines to institutional protocols
Chen et al. 29.07.2020 Chinese Society of Anesthesiology/Chinese Association of Anesthesiologists	Hospital scrubs inside and protective coveralls outside; medical protective mask, disposable surgical cap, goggles/face shield; wear disposable medical latex gloves and boot covers.	Airway team (experienced), patient's mouth covered with two wet gauze strips during preoxygenation, RSI, VL, or Bronchoscope/Fiberscope (airway manager is familiar and brings distance to the airway), filter between tube, no auscultation Respirator only for COVID-19 patients after use even with filter or need to be disinfected; closed suction system	n/a	If patient under HFNC or NIV before intubation use caution for aerosol and droplets	n/a	Two wet gauzes, rather avoid BMV	Consider midazolam 2–5 mg, etomidate 10–20 mg, propofol (if stable), succinylcholine 1 mg/kg; if rocuronium is used, have sugammadex nearby for a CICO	Protection of healthcare workers

Abbreviations: AGP: aerosol-generating procedure; ASA: American Society of Anesthesiologists; ATI: awake tracheal intubation; CICO: “can't intubate, can't oxygenate”; CPAP: continuous positive airway pressure; eFONA: emergency front-of-neck airway; HFNC: High-flow nasal cannula; IBW: ideal body weight; NIV: non-invasive ventilation; NMB: neuromuscular blockade; OR: operating room; PAPR: powered air-purifying respirator; PEEP: positive end expiratory pressure; PPE: personal protective equipment; RSI: rapid sequence induction; SGA: supraglottic airway device; TBW: total body weight; TIVA: total intravenous anesthesia; VL: video laryngoscopy; WHO: World Health Organization.