*7.2.2 Virus filters*

**7. Intubation**

*Special Considerations in Human Airway Management*

**7.1 Introduction**

challenging.

**7.2 Before intubation**

*7.2.1 Communication*

**Figure 1.**

**8**

handy before progress to intubation.

phone kept inside water seal cover.

Endotracheal intubation is considered a very high-risk procedure in COVID 19

All equipment should be prepared with tracheal intubation checklist (see - **Figure 1**) [33] and preferably COVID 19 airway intubation trolley to be prepared figure [34], medications should be prepared in advance, crash trolley should be

In operating theater or in ICU setting delegated person, an outside-room "run-

The runner can communicate with the inside personnel using special pager or

ner" to provide additional outside-room equipment and medications.

*Checking list an example of emergency intubation checklist from safe airway society [32].*

patients. For many reasons usually COVID 19 patients who need intubation urgently are critically ill patients with severe hypoxemia and respiratory failure. Desaturation is very quick because of depleted oxygen reserve and high consumption with regards to severe inflammatory status also involvement of other organ failure makes airway management of these cases are challenging. Special attention to the previous mentioned points may provide avoidance of major complications and avoidable deaths ensuring the safety of healthcare workers involved. Sever hypoxemia during ICU intubation has been reported in 25% [31]. In general, physiologically and anatomically airway management in critically ill patients consider

Using of heat moisture exchanger (HME filter) has been advised by many centers which can filter the viruses including Corona virus by 99 percent. HME filter should be attached most proximal to patient i.e. directly to ETT or between the mask and bag of Ambu, another alternative to HME filter that can be used is high efficiency particulate air filter (HEPA filter). Another HME filter is kept between expiratory limb of anesthesia circuit and anesthesia machine (**Figure 2**).

#### *7.2.3 Video laryngoscope*

In covid 19 pandamic Video laryngoscopy is recommended as first line option for airway management the rational be [44]:

Higher chance for ETT pass first attempt, reducing chance of infection for the intubator by increasing the distance between the patient airway and the incubators face also use of special drapes is possible and might increase the level of protection, better intubation view can be achieved especially in full PPE situation where the face shield and googles (with fog) are obstructing clear view.

Two pieces of video laryngoscope (display, single use probe) are better to be used to make sure the intubator's face is far away from the patient's mouth during the procedure [36] in addition, first pass success rate is much higher in experienced manager with video laryngoscope than direct laryngoscope.
