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 Journal of Clinical Anesthesia 65 (2020) 109877
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
journal homepage: www.elsevier.com/locate/jclinane
Correspondence
Airway management and ventilation principles in COVID-19 patients
A R T I C LE I N FO
Keywords:
COVID-19
SARS-CoV-2
Influenza
Pandemic
Airway management
Ventilation
To the Editor:
Since the beginning of the SARS-CoV-2 pandemic, there have been
2,435,876 confirmed COVID-19 cases, with an observed mortality rate
of approximately 8%. In COVID-19 patients, an impending challenge is
acute hypoxemic respiratory failure due to the difficulties of how to
protect the airways and the method of ventilation. SARS-CoV-2 spreads
mainly through droplets, while the highest viral load of SARS-CoV-2
presents in the sputum and in upper airway secretions. All procedures
to secure airway patency are, therefore, aerosol-generating procedures,
which increase the risk of infection for medical personnel.
Based on Wuhan, China medical staff experiences in the manage-
ment of COVID-19 patients, the Chinese Society of Anesthesiology re-
commended endotracheal intubation even for COVID-19 patients in
respiratory distress with no improvement, tachypnea (respiratory
rate > 30 per minute), and poor oxygenation (PaO2 to FiO2
ratio < 150 mmHg) after 2-h high-flow oxygen therapy or noninvasive
ventilation [1]. Zhang et al. indicated that for severe pneumonia pa-
tients who show poor prognosis and are anticipated to deteriorate, early
respiratory support with tracheal intubation may be advised to improve
outcomes [2].
The British guidelines for airway management, on the other hand,
do not provide specific guidelines for intubation. Additionally, they
specify the use of supraglottic airway devices (SADs) as a method of
protecting the airway [3]. SADs customarily offer an alternative to
endotracheal intubation. As indicated by Schmidbaue et al., the use of
SADs with inspiratory pressures of 20 mbar appears to be safe con-
cerning the potential risk of intragastric insufflation. During resuscita-
tion or transport of a patient with the danger of the device apt to unseal
or leak infected respiratory droplets, it is worth considering the use of
endotracheal intubation.
Both hospitals and ambulances are commonly equipped with lar-
yngoscopes with Miller or Macintosh blades which serve as the main
practice of intratracheal intubation; however, in the case of patients
with a highly contagious viral disease, including COVID-19, respiratory
tract protection should be done as soon as possible and by the most
experienced person on the team. Furthermore, if possible, direct lar-
yngoscopy should be delayed, and video laryngoscopy performed in-
stead. Arulkumaran et al. highlight the advantage of utilizing video
https://doi.org/10.1016/j.jclinane.2020.109877
Received 26 April 2020; Accepted 16 May 2020
0952-8180/ © 2020 Elsevier Inc. All rights reserved.
T
laryngoscopy over direct laryngoscopy in reducing the risk of esopha-
geal intubation (OD = 0.32; 95% CI [0.14, 0.70]), airway trauma
(OR = 0.74; 95% CI [0.34, 1.62]) or inducing hypotension (OR = 1.49;
95% CI [1.00, 2.23]) [4].
Due to the challenges resulting from the use of full PPE AGP, the
correct position of the endotracheal tube should be confirmed with the
use of exhaust carbon dioxide detectors, which, apart from denoting
CO2 level during cardiopulmonary resuscitation, will also indirectly
show the quality chest compression [5].
During ventilation of patients with acute respiratory distress syn-
drome, it is recommended to use a higher PEEP strategy (PEEP > 10 cm
H2O) with low tidal volume ventilation (4–8 mL/kg of predicted body
weight). Targeting plateau pressure should additionally be < 30 H2O.
Such ventilation is the best method to protect the lungs of a patient with
acute respiratory distress syndrome.
In summary, the outbreak of SARS-CoV has created a global health
crisis that has had a profound impact on patient ventilation techniques.
The Chinese Society of Anesthesiology recommends endotracheal in-
tubation based on the gathered experience of patient care by Wuhan,
China medical personnel; the British guidelines for airway manage-
ment, however, do specify such guidelines instead indicating SADs as a
method of protecting the airway. The current COVID-19 pandemic
setting, however, yield concern over the danger of using devices that
might unseal or leak infected respiratory droplets, during resuscitation
or transport of patients, instead endotracheal intubation should be
considered. Furthermore, the use of PPE AGP by medical personnel
pinpoints the need for tools to confirm the correct placement of en-
dotracheal intubation potential via an exhaust carbon dioxide detector,
which will simultaneously denote CO2 levels and chest compression
quality during CPR.
Declaration of competing interest
The authors declare no conflict of interest.
References
[1] Zuo MZ, Huang YG, Ma WH, Xue ZG, Zhang JQ, Gong YH, et al. Chinese Society of
Anesthesiology Task Force on Airway Management: expert recommendations for
Correspondence Journal of Clinical Anesthesia 65 (2020) 109877

tracheal intubation in critically ill patients with novel coronavirus disease 2019. Chin
Med Sci J 2020. https://doi.org/10.24920/003724. Epub ahead of print.
[2] Zhang L, Li J, Zhou M, Chen Z. Summary of 20 tracheal intubation by anesthesiol-
ogists for patients with severe COVID-19 pneumonia: retrospective case series. J
Anesth 2020. https://doi.org/10.1007/s00540-020-02778-8. Apr 17.
[3] Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus
guidelines for managing the airway in patients with COVID-19: guidelines from the
Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society,
the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists.
Anaesthesia 2020. https://doi.org/10.1111/anae.15054. Mar 27.
[4] Arulkumaran N, Lowe J, Ions R, Mendoza M, Bennett V, Dunser MW. Video lar-
yngoscopy versus direct laryngoscopy for emergency orotracheal intubation outside
the operating room: a systematic review and meta-analysis. Br J Anaesth 2018
Apr;120(4):712–24. https://doi.org/10.1016/j.bja.2017.12.041.
[5] Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: adult advanced cardiovascular life
support: 2015 American Heart Association guidelines update for cardiopulmonary
resuscitation and emergency cardiovascular care. Circulation 2015;132(18 Suppl
2):S444–64. https://doi.org/10.1161/CIR.0000000000000261. Nov 3.
⁎
Lukasz Szarpaka, , Anna Drozdb, Jacek Smerekac
a
Medicine, Lazarski University, Warsaw, Poland
b
Polish Society of Disaster Medicine, Warsaw, Poland
c
Department of Emergency Medical Service, Wroclaw Medical University,
Wroclaw, Poland
E-mail address: Lukasz.szarpak@gmail.com (L. Szarpak).

⁎
Corresponding author at: Medicine, Lazarski University, Swieradowska 43,
02-662 Warsaw, Poland.