Emergency airway management in COVID-19 context

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  • This guideline applies to all patients requiring intubation in ED, and all patients with respiratory failure in paediatric and neonatal ICU requiring airway management. It must be read in conjunction with the Emergency airway management CPG

    See also

    Emergency airway management (non COVID-19)
    Intubation checklist

    Key points

    1. Airway management in patients with COVID causes aerosolisation of virus 
    2. Use airborne precautions and the highest level of isolation available
    3. The most experienced airway team available should manage the airway


    Airway management in patients with COVID-19 is associated with aerosol generation that carries the risk of virus transmission to healthcare workers, and in turn other patients. 

    Aerosol Generating Procedures (AGPs)

    Face mask ventilation

    Oropharyngeal suctioning

    Ventilation via a supraglottic airway (SGA)    
    eg laryngeal mask airway (LMA)

    CPR on patient prior to intubation

    Intubation including insertion of an SGA

    Extubation including removal of an SGA

    Open suctioning of endotracheal tube (ETT) (in-line suction is preferred)

    Non-invasive ventilation / high flow nasal  
    cannula therapy (HFNC) / nebuliser therapy

    Continuous nitrous oxide sedation



    Prepare environment

    • Management must occur in the highest level of isolation available: negative pressure room if available and appropriate
    • Personnel should be kept to a minimum and physical distancing should be maintained if possible; restrict personnel to those with most expertise
    • Ensure that the child’s accompanying support person is wearing appropriate PPE
    • Minimise equipment in the room during the AGP by only selecting equipment necessary for airway plans. Induction agent, muscle relaxant and other necessary medications should be drawn up and kept in room
    • Place Heat and Moisture Exchanger (HME) filters in the circuit on the ventilator side of any potential site for circuit disconnection including ventilator side of the face mask
      Image used with permission from Children's Health Queensland Hospital and Health Service
    • Have a staff member outside the room to pass equipment that was not initially inside, and prevent unnecessary staff from entering the environment (consider using communication devices)
    • Limit unnecessary thoroughfare into the procedure room. Minimise repeated entry and exit of staff
    • Have appropriate waste bins available, including a clear plastic bag or bin liner to place soiled reusable equipment temporarily until cleaned
    • Sedative premedication and topical anaesthetic cream are only applicable in the conscious child (but do not delay for emergency airway management)

    Airborne PPE must be used when treating high risk patients during AGPs

    • N95 mask
    • Eye protection (face shield if available)
    • Gown
    • Gloves (preferably 2 pairs)
    • Ensure sufficient PPE is stored outside the room for staff who may need to enter to assist emergently

    Airway Management

    • Most experienced clinician airway team available should manage airway
    • Minimise interval between removal of patient’s PPE and application of facemask
    • Ensure facemask is the appropriate size, use two person techniques when possible
      Image used with permission from Children's Health Queensland Hospital and Health Service 
    • An emergency intubation checklist and other cognitive aids should be used during emergency airway management. Please see examples below of a COVID-19 Airway Trolley Template and Emergency Intubation Plan
    • Minimise aerosolisation of virus by:
      • Avoid HFNC - use acceptable oxygen flow (eg 2L / min)
      • Consider using video assisted laryngoscopy if available to increase the likelihood of first pass success, and to maintain distance from the oropharynx
      • NB C-MACTM preferred over using the GlideScopeTM (latter only if difficult laryngoscopy is anticipated)
      • Intubate with a cuffed ETT. Inflate cuff as per unit guideline prior to commencement of IPPV

    Example COVID-19 Airway Trolley Template


    Example Emergency Intubation Plan
    Post intubation

    • Avoid contamination from the laryngoscope blade. Place blade and handle (and C-MACTM lead) into an open plastic bag or bin liner
    • Clamp ETT during circuit disconnections for transfer, unless apnoeic, or leave filter attached to ETT


    • Ideally done in PICU, NICU or operating theatre rather than ED
    • Minimise staff in the room
    • After airway patency and spontaneous ventilation confirmed, place a Hudson mask or nasal prongs with a surgical mask on top
    • Consider emergence delirium prophylaxis to minimise crying / screaming
    • Consider additional anti-emesis to avoid vomiting
    • If upper airway obstruction is anticipated, early insertion of SGA (LMA or oropharyngeal airway) should be considered

    After airway management

    • Immediately dispose of single use equipment in an appropriate clinical waste bin
    • Reusable equipment must be thoroughly cleaned
    • Dispose of ventilating circuits if saturated with condensation or visibly soiled

    Difficult laryngoscopy in COVID-19 patients

    Unanticipated difficult laryngoscopy is rare in infants and children. If an experienced clinician has been unable to successfully intubate a child on the first attempt, the situation should be considered a difficult laryngoscopy. To ensure safety of the child and staff, do not perform repeated attempts at direct laryngoscopy. Consider bag mask oxygenation or insert LMA and call for help.  Pay attention to not contaminating the environment further. The next attempt should be the best attempt and involve an advanced intubation technique using video laryngoscopy or flexible intubating bronchoscopy

    For anticipated difficult laryngoscopy, advanced intubation equipment should be in the room or consider moving to operating theatre

    In-line suction sizing

    If ongoing suctioning required, use closed in-line suctioning systems (come in different types depending on the size). Choose the size of suction catheter based on the size of the ETT

    See the video here for more information

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services. 

    Additional resources

    NSW airway management resources
    Queensland airway management checklist

    Last updated January 2022

  • Reference List

    1. Long E, Fitzpatrick P, Cincotta DR, et al 2016, A randomized controlled trial of cognitive aids for emergency airway equipment preparation in a Paediatric Emergency Department, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 24:8.
    2. Long E, Barrett MJ, Peters C, et al, 2019, Emergency intubation of children outside of the operating room. Paediatric Anaesthesia 00:1-12
    3. Sabato SC, Long E, 2016, An institutional approach to the management of the 'Can't Intubate, Can't Oxygenate' emergency in children. Paediatr Anaesth. 26(8):784-93.