• **Difficult airway management:**

Difficulty can happen in many aspects:


Declare the status clearly to team members is very important, in case FONA needed the recommended technique is the one to minimize aerosol generating i.e. The scalpel bougie-tube technique as using high flow oxygen could generate

#### **Figure 5.**

*(a) Tracheal intubation adapted for COVID 19 patient & (b) CICO adapted for COVID 19 patients. Taken with permission from Difficult Airway Society (DAS) 2015 guidelines [45].*

laryngoscope is not available for any reason direct laryngoscopy could be other

*(*√*): Two-handed two-person bag-mask technique with the VE hand position; the second person squeezes the*

• Tube size should be reliable with patient condition and should be the biggest diameter size that fit the patient preferably supplied with subglottic suction port.

• After tube insertion under direct vision, inflate the ETT cuff between 20–30 cmH2O then connect the circuit provided by HME/HEPA filter, anesthesia machine or mechanical ventilator should be in standby mode at this point, after making sure the ETT cuff is inflated well, we can start mechanical ventilation. Waiting for capnography waveform to confirm correct tube site and observing

• Please note that auscultation is not practical with full PPE and difficult to perform so, we have to rely on other parameters. Airway pressure can help the intubator or heath care provider to figure out a bronchial intubation as well as

circuit leak. The reason of not using auscultation is not the impractibal procedure, the reason is not to increase the contamination risk)

• Some procedure will increase the risk of circuit disconnection or ETT

• For ultimate reducing possible contamination during ventilation It is

• During intubation if suction needed it is advised to use close loop suction, in

displacement so, attention during these procedures must be taken to avoid any complication and contamination: examples of these procedures are patient proning, nasogastric tube insertion, Trans Esophageal Echocardiography

recommended by safe airway society to arrange the circuit in this order, i.e.

option using Macintosh blade with Gum Elastic Bougie (GEB) help.

*bag. (X): The CE hand position, which should be avoided. (image courtesy Dr. Nabil Shallik).*

chest movement as mentioned before.

*Special Considerations in Human Airway Management*

(TEE) procedure, or oral suctioning.

keep the ETCO2 sample line always distal

line catheter suction.

**Figure 4.**

• to the patient.

**12**

aerosols and contamination [46], Front neck kit should be available immediately in case needed however it is better keep nearby the room not inside to avoid contaminate it.

v. Limit the need for subsequent staff interactions with:

• Adequate analgesia; consider regional anesthesia. (What kind of regional anesthesia for extubation? If it is an advice for surgery it

vii. Antitussive drugs, such as Remifentanil, Lidocaine, and Dexmedetomidine, reduce the risk of coughing and minimize agitation on extubation.

Many techniques have been described to minimize exposure to aerosols during

• Extubation with LMA as alternative to ETT (contraindicated; as it can generate

On the ICU there are times the ETT may need to be changed, either due to blockage or damage to the cuff. This is usually done with a tube exchanger, with the new ETT railroaded over the bougie. The lungs of a COVID-19 patient are diseased and more prone to trauma. It is advised to avoid blindly introducing a bougie into the trachea with the possibility of advancing it too deep, and thus damaging the airways, with a potential to cause a pneumothorax. If the airway is not predicted to

reintubation with a fresh ETT using a video-laryngoscope would be the gentler way

• Ideally single use equipment is the best option in such a huge pandemic like COVID 19 pandemic, however because of the high transmission rate, applying this does not look practical especially with enormous number of infected people. It is really advised to avoid reusable equipment that will guarantee

be difficult, paralyzing the patient, preoxygenation, extubation and then

**11. Single vs. reusable equipment during COVID19 outbreak**

vi. Perform oropharyngeal suction with vigilance, as this may generate

Ensure good sedation before extubation. Efforts to prevent cough during extubation should be implanted including possible use of medications like Dexmedetomidine, Lidocaine, and/or opioids if there is no contraindication.

• Prophylactic and anti-emetics.

*DOI: http://dx.doi.org/10.5772/intechopen.96889*

*Airway Management in COVID-19 as Aerosol Generating Procedure*

should take place above???)

extubation although no clear evidence behind them [50].

• Mask over tube technique with attached filter

• Extubation with lightweight barrier hood device [51]

aerosols.

**10. Extubation technique**

• Extubation under plastic cover

**10.1 Endotracheal tube exchange**

to do it.

**15**

aerosol and contact contamination,
