It is advisable to perform neuromuscular monitoring.
Employment of a videolaryngoscope, ideally disposable but with a separate screen to minimize patient contact, is strongly recommended.Should tracheal intubation fail, gentle manual ventilation may be used, with a maximum of two attempts at tracheal intubation subsequently employed (with consideration of position change, device, and technique between attempts).
Should tracheal intubation fail twice, or if a rescue airway is needed, it is strongly advised that a second-generation supraglottic device, preferably one that permits flexible bronchoscopic intubation, be used.
Consider an early emergency front-of-neck airway (surgical or percutaneous cricothyroidotomy) before a “cannot intubate, cannot oxygenate” scenario independently of critical arterial oxygen desaturation.
An experienced operator should perform an indicated ATI; employment of intravenous sedation may minimize coughing.
Minimize aerosol or vaporized local anesthesia delivery, and consider using mucosal atomizers, swabs, and tampons, as well as (if clinical expertise permits) nerve blocks.
To reduce the risk of cross-contamination, employ single-use flexible bronchoscopes; a separate screen is strongly advised.
Because it is faster than flexible bronchoscopy, ATI with videolaryngoscopy can be considered.
Despite the potential for aerosolization, tracheostomy with local anaesthesia must be considered in the event of a failed ATI.
In the event of a “cannot intubate, cannot oxygenate” scenario, carry out an emergency front-of-neck airway.
If emergency tracheal intubation is required for a COVID-19 patient, personal protective equipment (PPE) must be donned by team members prior to airway management. Gentle facemask ventilation may be required in a hypoxic patient to give more time to the patient and clinicians.
Place high-efficiency particulate air filters between the primary airway device and the breathing circuit, including the expiratory limb of the circuit once the patient is connected to the ventilator.
Unnecessary respiratory circuit disconnections should be avoided, in order to prevent viral dispersion. If disconnection is required, optimize patient sedation to prevent coughing, turn the ventilator to stand-by mode, and clamp the tracheal tube.
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