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GUIDELINES Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 387-389 Airway management and COVID-19 patient -Saudi Anesthesia Society guidelines- Mohammed K Al Harbi1, Ahmed Abdulmomen2, Fahad Al Qurashi3, Maan Kattan4, Abdulaziz E Ahmad5, Abdelazeem Eldawlatly6 1 Asst. Professor and Consultant Anesthesiologist, King Saud Bin AbdulAziz University for Health Science, Riyadh, KSA 2 Professor of Anesthesia and Critical Care Medicine, College of Medicine, King Saud University, Riyadh, KSA 3 Consultant and Chief of Anesthesia and Critical Care Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Jeddah, KSA 4 Asst. Professor and Consultant Thoracic and Regional Anesthesiologist and Pain Management KAMC/King Saud Bin AbdulAziz University for Health Science, Jeddah, KSA 5 Assistant Professor of Anesthesia, College of Medicine, King Saud University, Riyadh, KSA 6 Professor of Anesthesia, College of Medicine, King Saud University, Riyadh, KSA Correspondence Address: Prof. Abdelazeem Eldawlatly Department of Anesthesia, College of Medicine, King Saud University, Riyadh KSA Source of Support: None, Conflict of Interest: None Check DOI: 10.4103/sja.SJA_265_20 Date of Submission 02-Apr-2020 Date of Decision 02-Apr-2020 Date of Acceptance 02-Apr-2020 Date of Web Publication 17-Apr-2020

The Saudi Anesthesia Society (SAS) in line with the Mission and Vision of the Kingdom of Saudi Arabia to contain the new coronavirus disease (COVID-19) is pleased to develop a statement regarding airway management of suspected/confirmed patients with this virus, to ensure the safe practice in dealing with the patient as well as protecting the medical staff from getting the infection. In this report, we have summarized the guidelines necessary for airway management of suspected/confirmed COVID-19 patient. Since the COVID-19 outbreak is up to date existed, therefore this report is considered as interim guidelines for airway management of the suspected/confirmed patients. The guidelines will be revisited and modified in the future, if necessary.

Keywords: Airway; Anesthesia; COVID 19

Objectives

1. To provide updated information about COVID-19.
2. To establish guidelines related to airway management in a patient with suspected/confirmed COVID-19.
3. To recommend Personal protective equipment (PPE) suitable for airborne, droplet and contact isolation precaution.

1. A patient with Acute Respiratory Illness such as fever, cough and shortness of breath, and with no other etiology that fully explains the clinical presentation, and a history of travel to or residence in a country, area or territory that has reported local transmission of COVID-19 disease during the 14 days prior to symptom onset (for updated reporting, see the situation reports at https://www.who.int/emergencies/diseases/novelcoronavirus -2019/situation- reports/); OR
2. A patient with any Acute Respiratory Illness who has been a contact of a confirmed or probable case of COVID-19 during the 14 days prior to the onset of symptoms (see the definition of contact below); OR
3. A patient with Severe Acute Respiratory Infection such as fever, cough and shortness of breath who requires hospitalization and who has no other etiology that fully explains the clinical presentation.

• Providing direct care for patients with COVID-19 disease without using proper personal protective equipment (PPE)
• Staying in the same close environment as a COVID-19 patient (including sharing a workplace, classroom or household or being at the same gathering)
• Travelling in close proximity with (that is, having less than 1 meter separation from) a COVID-19 patient in any kind of conveyance.

1. Preparation/ahead plan:



• Assign the minimum needed numbers of expert practitioners to minimize exposure
• Formulate early plans: prepare all medications and airway tools you need in advance and aim to intubate as early as possible
• A clear sign on the door of the designated OR to minimize exposure
• Allow time to all staff to apply PPE and barrier precautions with presence of an observer.



2. Full PPE:



• Hand hygiene
• Disposable N-95 masks (needs fitting test), goggles, footwear, water-proof gowns and gloves (consider double glove technique) [Figure 1]
• Power Air Purifying Respirator (PARP): A PAPR should be worn for high-risk aerosol-generating procedures. These respirators also meet centers for disease control and prevention (CDC) guidelines for protection against TB exposure. Reusable respirators that are typically loose fitting hooded or helmeted ♣ Equipped with a battery-powered blower to force air through a particle filter for the wearer to breathe ♣ Capable of reducing airborne exposures at efficiencies that typically exceed the N95, using a high-efficiency particulate air (HEPA) filter [Figure 2].

Figure 1: N95 Click here to view

Figure 2: PARP Click here to view




3. Team dynamics:



• Clear role to the team members
• Clear communication of airway management plan
• Closed – loop communication
• Cross monitoring by all team members for potential contamination.



4. Transferring:



• Directly to negative pressure OR: should NOT brought to holding or PACU areas
• Avoid high flow oxygen: use minimum flow to keep SPO2 <94%.
• Ensure availability of high quality HMEF (heat and moisture exchange filter)/HEPA (high efficiency particulate air) filters to be placed in between the facemask and breathing circuits or between facemask and reservoir bag.



5. Airway:



• Airway management should be done by the most experienced practitioner
• Standard ASA monitoring should be applied before induction of anesthesia
• Minimize leak from facemask by applying two-hand technique
• Perform Rapid Sequence Induction (RSI) to avoid bag-mask ventilation
• Use video laryngoscopy (disposable blade)
• Positive pressure ventilation only after ETT cuff is inflated
• Lowest gas flow needed to maintain acceptable oxygenation.



6. Dispose:



• Re-sheath the laryngoscope immediately after intubation
• Seal all used airway equipments in a double zip-locked plastic bag for disposal or decontamination/disinfection [Figure 3]
• Avoid unnecessary ETT disconnection from circuit
• In case of necessity of tube disconnection, PPE should be on, clamp the tube and the ventilator should be on standby mode.




Figure 3: Plastic cover on anesthesia equipment (case in progress) Click here to view




7. Doffing:



• Strict adherence to proper de-gowning and doffing steps
• Hand hygiene
• Team debriefing
• After doffing avoid touching the face/hair before washing the hands.

References

1.	World Health Organization. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019. [Last accessed on 2020 Apr 02].
2.	Kamming D, Gardam M, Chung FI. Anaesthesia and SARS. Br J Anaesth 2003;90:715-8.
3.	ASA-APSF joint statement on non-urgent care during COVID-19 outbreak. Available from: https://www.asahq.org/about-asa/newsroom/news-releases/2020/03/asa-apsf-joint-statement-on-non-urgent-care-during-the-covid-19-outbreak. [Last accessed on 2020 Mar 23].
4.	Coronavirus-guidance for anaesthesia and perioperative care providers. Available from: https://www.wfsahq.org/components/com_virtual_library/media/d6b96b32880ef98a533a191bf12 47b3b-covid-19-airway-management-infographic.pdf. [Last accessed on 2020 Apr 02].

This article has been cited by 1 Clinical recommendations for in-hospital airway management during aerosol-transmitting procedures in the setting of a viral pandemic Alexander Fuchs, Daniele Lanzi, Christian M. Beilstein, Thomas Riva, Richard D. Urman, Markus M. Luedi, Matthias Braun Best Practice & Research Clinical Anaesthesiology. 2021; 35(3): 333 [Pubmed] | [DOI]