In face of the need for airway management and endotracheal intubation in COVID-19 infected patients with respiratory failure, the Taiwan Association of Anesthesiologists has put together an expert recommendation for all medical professionals.

1. Before approaching patients with coronavirus infection, remember that “personal protection” is priority. Check relevant equipment and use contact isolation precautions as described in point 2.

   In particular, plan ahead and allow sufficient time to remove all obstacles before contacting the patient.

   Precautions: before intubation, review and practice wearing and removing protective masks, gloves, and clothing. Pay close attention to avoid self-contamination.

2. All staff and visitors entering the isolation ward should wear personal protective equipment (PPE) as recommended:

   (1) Disposable fluid resistant jumpsuits.

   (2) Double-layer gloves: the outer gloves should at least extend to/ cover the jumpsuit cuffs.

   (3) Masks should be N95 grade or above, or Powered Air Purifying Respirators (PAPR).

   (4) Disposable protective face shield, goggles, disposable waterproof shoe cover or rubber boots. The length of boots should extend up to mid-calf.

   (5) Disposable waterproof apron: when the patient has symptoms of vomiting or diarrhea, wear a waterproof apron or an apron made of PVC, rubber or other waterproof materials. The aprons should be easily removable, such as those with Velcro attachments.

   (6) Poster of putting on and taking off protective equipment sequences should be posted wherever equipment is being worn and removed. Hand hygiene equipment such as soap and water or alcohol-based dry cleaners should be provided.

   (7) Medical waste bin should be provided wherever protective equipment is being worn and removed.

   (8) A team (Buddy System) should overlook the sequence of putting on and taking off PPE. A trained observer assists to check whether the equipment was completely and properly put on or removed while the intubating personnel put on and off PPE.

3. Check standard monitors, intravenous access, intubation equipment, intubation medications, ventilator and sputum suction equipment.

4. Avoid awake fibroptic intubation unless otherwise specified. Nebulizing local anesthetics will nebulize the virus. Disposable video assisted intubation devices are advised. Back-up equipments such as supraglottic airways (SGA), laryngeal masks (LMA) and emergent front of neck access (eFONA) should also be readily available.

5. Bed up Head elevation (BUHE) position: This position increases functional residual capacity (FRC) thus will improve oxygen reserve and increase the safety time for intubation. Sniffing position can make intubation easier.

6. For patients not under high flow nasal cannula (HFNC) or noninvasive ventilation (NIV) therapy: Preoxygenation with 15 L/min oxygen via Non-Rebreathing Mask for more than 5 minutes. Avoid mask ventilation to prevent potentially aerosolize the virus and increase spread from the respiratory tract. For patients under HFNC or NIV, whether to stop respiratory treatment or not is still controversial. Consider give glycorryolate to reduce oral secretions, avoid secretion spread, and avoid visually obstructing intubation field. If there is no glycorryolate, it may be replaced by atropine, but the effect is poor and there are side effects of tachycardia.

7. Use rapid sequence intubation (RSI) in a negative pressure environment and ensure that a skilled assistant can provide adequate cricoid pressure. Rocuronium 1–1.5 mg/kg may be better than Succinylcholine. It can maintain relative longer paralysis and reduce patient cough or fighting with ventilator. After Rocuronium bolus, one must wait for 60–90 seconds for fully onset before one start the endotracheal intubation. If the patient’s alveolar arterial difference is high and cannot tolerate apnea for 30 seconds, the RSI procedure may need to be modified.

8. Remove NRM or other respiratory devices off the patient just before intubation. It is recommended to use a disposable Videoscope (such as Glidescope) for intubation. The patient may be intubated from a relative distant position with a better and clearer field of vision with a Videoscope compared to the traditional laryngoscopes.

9. Make sure the high-efficiency particulate air (HEPA) filter is placed immediately adjacent to patient mask, i.e., between the patient mask and the breathing circuit, or between the patient mask and the Ambu bagging system.

10. To confirm position of tracheal intubation, use end-tidal CO2 (ETCO2) or disposable colorimetric ETCO2. Confirmation by auscultation via stethoscope is not recommended. Connect the HEPA filter to perform mechanical ventilation. Stabilize the patient to avoid spread of virus.

11. If intubation is unsuccessful, consider SGA with low driving pressure (< 20 cm H2O) under pressure control ventilation (PCV). If one tries to use manual mask ventilation or use volume control mode, the pressure may be higher than sealing pressure of SGA and the gas will overflow outside the airway. It may also be overflown into the esophagus thus open the sphincter and cause regurgitation. If difficult intubation is encountered, eFONA may be considered early. Suggammadex is not recommended to reverse muscle relaxation. Reversal may cause coughing.

12. All airway equipment must be sealed with double zipper plastic bags and removed for decontamination and disinfection.

13. After leaving the negative pressure environment, an assistant should wipe all surfaces with appropriate disinfectant (as instructed by the hospital).

14. After removing protective equipment, avoid touching hair, face, or eyes before washing hands.

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