Difficult Airway Management in Adult COVID-19 Patients: Statement by the Society of Airway Management

The COVID-19 disease, caused by Coronavirus SARS-CoV-2, often results in severe hypoxemia requiring airway management. Because SARS CoV-2 virus is spread via respiratory droplets, bag-mask ventilation, intubation, and extubation may place health care workers (HCW) at risk. While existing recommendations address airway management in patients with COVID-19, no guidance exists specifically for difficult airway management. Some strategies normally recommended for difficult airway management may not be ideal in the setting of COVID-19 infection. To address this issue the Society for Airway Management (SAM) created a task force to review existing literature and current Practice Guidelines for management of the difficult airway by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. SAM task force created recommendations for management of known or suspected difficult airway in the setting of known or suspected COVID-19 infection. The goal of the task force was to optimize successful airway management while minimizing exposure risk. Each member conducted a literature review on specific clinical practice section utilizing standard search engines (PubMed, Ovid, Google Scholar). Existing recommendations and evidence for difficult airway management in COVID-19 context were developed. Each specific recommendation was discussed among task force members and modified until unanimously approved by all task force members. Elements of AGREE Reporting Checklist for dissemination of clinical practice guidelines were utilized to develop this statement. Airway management in the COVID-19 patient increases HCW exposure risk. and difficult airway management often takes longer, may involve multiple procedures with aerosolization potential, strict adherence to personal protective equipment (PPE) protocols is mandatory to reduce risk to providers. When patient's airway risk assessment suggests awake tracheal intubation is an appropriate choice of technique, procedures that may cause increased aerosolization of secretions should be avoided. Optimal preoxygenation before induction with tight seal facemask may be performed to reduce risk of hypoxemia. Unless the patient is experiencing oxygen desaturation, positive pressure bag-mask ventilation after induction may be avoided to reduce aerosolization. For optimal intubating conditions, patients should be anesthetized with full muscle relaxation. Videolaryngoscopy is recommended as first-line strategy for airway management. If emergent invasive airway access is indicated, we recommend a surgical technique such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. This statement represents recommendations by SAM task force for the difficult airway management of adults with COVID-19 with the goal to optimize successful airway management while minimizing the risk of clinician exposure.

An Innovative Use of an Online Procedure Logbook to Improve Airway Training among Anesthesiology Residents

INTRODUCTION

We performed a single-institution pilot study to determine the potential value of an electronic logbook of airway procedures performed during a one month airway rotation for anesthesiology residents. For two years, CA-3 residents taking an advanced airway management rotation entered all airway procedures in this electronic logbook. We expected this logbook to produce results of potential use to program directors by determining the numbers of specific procedures performed by each resident.

METHODS

All residents taking this rotation were required to enter specific data from each airway procedure into our on-line electronic logbook. Entered information was available in tabular form to the program director and each resident. Numbers of procedures with each technique were compared among residents and to a previously determined target number of procedures for several techniques.

RESULTS

Sixty seven residents entered data for nine specific airway procedures over a 24 month pilot study duration. When compared to target numbers of procedures for specific techniques, we discovered most residents performed less than 2 standard deviations from the target number with flexible fiberoptic intubation (usually exceeding the target number) but greater than 3 standard deviations with surgical and percutaneous procedures (usually falling short of the target number). Analysis also determined that resident experience exhibited considerable variability as shown by the ranges of several techniques. Though there was a wide range of numbers for most techniques, most were within two standard deviations of the mean values of the technique.

CONCLUSIONS

The authors conclude that this electronic logbook was easily administered at minimal cost and administrative effort. Future studies may confirm the logbook as a feasible intervention permitting anesthesiology training programs to in crease the breadth of data related to their resident airway education.