Aligning difficult airway guidelines with the anesthetic COVID-19 guidelines to develop a COVID-19 difficult airway strategy: a narrative review

J Anesth. 2020 Dec;34(6):924-943. doi: 10.1007/s00540-020-02819-2. Epub 2020 Jul 8.


The coronavirus disease 2019 (COVID-19) pandemic is caused by a coronavirus that is transmitted primarily via aerosol, droplets or direct contact. This may place anesthetists at higher risk of infection due to their frequent involvement in aerosol-generating airway interventions. Many anesthethetic COVID-19 guidelines have emerged, whose underlying management principles include minimizing aerosol contamination and protecting healthcare workers. These guidelines originate from Australia and New Zealand, Canada, China, India, Italy, Korea, Singapore, the United States and the United Kingdom. Hospitalized COVID-19 patients may require airway interventions, and difficult tracheal intubation secondary to laryngeal edema has been reported. Pre-pandemic difficult airway guidelines include those from Canada, France, Germany, India, Japan, Scandinavia, the United States and the United Kingdom. These difficult airway guidelines require modifications in order to align with the principles of the anesthetic COVID-19 guidelines. In turn, most of the anesthetic COVID-19 guidelines do not, or only briefly, discuss an airway strategy after failed tracheal intubation. Our article identifies and compares pre-pandemic difficult airway guidelines with the recent anesthetic COVID-19 guidelines. We combine the principles from both sets of guidelines and explain the necessary modifications to the airway guidelines, to form a failed tracheal intubation airway strategy in the COVID-19 patient. Valuing, and a greater understanding of, these differences and modifications may lead to greater adherence to the new COVID-19 guidelines.

Keywords: Airway management; COVID-19; Coronavirus; Difficult airway; Tracheal intubation.

Publication types

  • Review

MeSH terms

  • Airway Management
  • Anesthetics*
  • Betacoronavirus
  • COVID-19
  • Coronavirus Infections*
  • Coronavirus*
  • Humans
  • India
  • Intubation, Intratracheal
  • Italy
  • Japan
  • Pandemics*
  • Pneumonia, Viral*
  • SARS-CoV-2
  • United States


  • Anesthetics