key: cord-0802447-221rp39v
authors: Şentürk, Mert; Tahan, Mohamed R. El; Shelley, Ben; SZEGEDI, Laszlo L.; Piccioni, Federico; Licker, Marc-Joseph; Karzai, Waheedullah; Gil, Manuel Granell; Neskovic, Vojislava; Vanpeteghem, Caroline; Pelosi, Paolo; Cohen, Edmond; Sorbello, Massimiliano; Bence, Johan; Stoica, Radu; Mourisse, Jo; Brunelli, Alex; Jimenez, Maria-José; Drnvsek-Globoikar, Mojca; Yapici, Davud; Morsy, Ahmed Salaheldin; Kawagoe, Izumi; Végh, Tamás; Navarro-Ripoll, Ricard; Marczin, Nandor; Paloczi, Balazs; Unzueta, Carmen; Gregorio, Guido Di; Wouters, Patrick; Rex, Steffen; Mukherjee, Chirojit; Paternoster, Gianluca; Guarracino, Fabio
title: Thoracic Anesthesia during the 2019 Novel Coronavirus Infection Pandemic: 2021 Updated Recommendations for Airway Management by the EACTAIC Thoracic Subspecialty Committee
date: 2021-07-27
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2021.07.027
sha: b3ecd3d62ef90a7d4e22a2678b05510d5e6f3b65
doc_id: 802447
cord_uid: 221rp39v

The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority and there is an increasing need to fully define the optimal oncological management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Health care providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer: an imminent spike due to mortality from acute COVID-19 infection and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were de-intensified, delayed or cancelled. The European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Anaesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectivity period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority and there is an increasing need to fully define the optimal oncological management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Health care providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer: an imminent spike due to mortality from acute COVID-19 infection and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were de-intensified, delayed or cancelled.

The European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Anaesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectivity period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

In early 2020, the members of the Thoracic Subspecialty Committee of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) released preliminary recommendations on the perioperative care of patients with ‗suspected' or ‗diagnosed' coronavirus infectious disease of 2019 (COVID-19) who undergo thoracic surgery. 1 Since the time of writing these preliminary recommendations, there have been subsequent surges of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) across several regions in the world. 2 As of May 12, 2021 , the number of confirmed cases and deaths increased around the world by +228% and +98%, respectively since the date of acceptance of publishing the EACTAIC recommendations on March 30, 2020. 3, 4 After the publication of the recommendations last year, there have been a huge number of studies, recommendations, and guidelines (many of which have been updated themselves), benefiting from new learning, and in places contradicting preliminary reports on diagnosis and management of patients with SARS-CoV-2 throughout the last year. Current practice might be also impacted by the widespread roll out of vaccination. There is therefore the need to update the preliminary EACTAIC recommendations for perioperative management of patients undergoing thoracic surgery during the multiple waves of COVID- 19 Consequently, the EACTAIC expert thoracic anesthesia panel implemented a living guideline model to provide an update to their guidance on the perioperative management of patients with ‗suspected' or ‗diagnosed' COVID-19 undergoing thoracic surgery. Considering the challenges of recurring peaks and new variants/mutations, the authors developed an updated set of expert recommendations concerning the infectivity period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic patients during the COVID-19 era.

Our consensus builds on four sources:

A. We electronically searched all major databases for literature concerning the management of COVID-19 patients. We electronically searched major databases (e.g. MEDLINE) and online (e.g. Google), to identify recent consensus recommendations, guidelines, relevant systematic reviews, randomized controlled trials (RCTs), observational studies, and case series. These electronic searches were performed looking for studies published in English until May 12, 2021 . Studies performed in patients undergoing thoracic surgery, and those with results which could be extrapolated for thoracic anesthesia practice were evaluated by a writing committee including six experts from the EACTAIC Thoracic Committee. The papers included were chosen through an agreement among the writing committee, including six experts of the EACTAIC Thoracic Committee (MS, MRT, BS, LLZ, FP, and M-JL). All authors were then asked if they agreed with the recommendations and newly added references through a simple survey without ranking the importance of the papers chosen. We also included any additional articles proposed by any of the other authors at this point.

B. We electronically searched specialist thoracic anesthesia societies' and groups' previous recommendations on the perioperative management principles for patients with potential SARS-CoV-2 infection focusing on unique aspects of thoracic anesthesia. [5] [6] [7] [8] [9] C. The thoracic subcommittee of EACTIC has performed a survey exploring changes in clinical practice occurring during the COVID-19 era to better understand how practice has evolved and to aid development of further general recommendations on the perioperative management of patients with ‗suspected' or ‗diagnosed' COVID-19 undergoing thoracic surgery (unpublished). This survey included a 36-item questionnaire to explore the changes in daily practice during the COVID-19 pandemic, emphasizing the general aspects of anesthesia, airway management and lung isolation, ventilation, and postoperative analgesia. The survey was sent by e-mail to 4060 subscribers to the EACTAIC newsletters from each of the different EACTAIC sub-specialties including cardiac, thoracic, vascular, intensive care and perfusion, starting from August 3, 2020, until February 2, 2021. Four-hundred-fourteen responses (10%) were received after sending nine reminders, 341 (82.4%) of them were returned with complete responses.

D. Finally, members of the subcommittee have discussed in light of these three sources to define their recommendations. The subcommittee members had the opportunity to review, discuss, and edit all recommendations, agree on the references used, and suggest inclusion of additional references through exchange of evolving manuscript versions. Additionally, the subcommittee members discussed any point of debate through a closed WhatsApp group and through email exchanges.

Here, the authors want to underline some important notes: First, although there are a huge number of studies published in one year about the management of COVID-19 patients, there are still very few studies that can be considered as providing -evidence-based‖ knowledge on which to base practice. Second, we observed that the differences between different countries and between different centers within the same country are often based on local logistics rather than the scientific background. Indeed, the long-term impacts of the SARS-CoV-2 disease have led to vast differences in practice (e.g., the regulations surrounding use of -personal protection equipment‖ (PPE) or preoperative screening of patients for COVID-19 infection).

The recommendations in this publication might be adapted to suit local clinical conditions, and available equipment and facilities, provided this can be done in a safe and controlled manner. As our goal was to update our initial consensus recommendations to guide all thoracic teams in their day-to-day clinical practice, we acknowledge limitations of the adopted methodology. Our document should perhaps therefore be considered as a basis for future Task Force discussions, seeking to develop a multi-society consensus taking into appropriate consideration new evidence uncovered during the COVID-19 pandemic.

It is crucial to determine when a patient confirmed to have SARS-CoV-2 is no longer infectious to allow decision making on the optimal timing of procedures after recovery.

Although there is a consensus between major surgical and anesthesiologic societies, that ‗in order to minimize infection spread, all known or suspected COVID-19-positive patients requiring surgical intervention must be treated as positive until proven otherwise', 10 the panel acknowledge that such consensus may not be consistent across different regions of the world.

The Centers for Disease Control and Prevention (CDC) provides guidance to decide when transmission-based precautions (e.g., isolation, use of personal protective equipment ‗PPE' and engineering controls) may be discontinued for hospitalized patients or home isolation may be discontinued for outpatients [click here] (Online supplement 1).

It has been consistently demonstrated that surgical mortality and complications are higher in patients with active or recent COVID-19 infection compared with patients without COVID-19 which highlights the need to consider postponing ‗elective' surgery after COVID-19

infection. Patients with ongoing symptoms of SARS-CoV-2 infection had higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively) even when elective surgery was delayed for a ≥ 7 weeks. 11 The COVIDSurg Collaborative and GlobalSurg Collaborative recommend delaying surgery for at least 7 weeks following SARS-CoV-2 infection whenever possible. 11 However, this 7-weeks interval needs to be carefully considered in the light of the following potential influential factors:

In general, patients with SARS-CoV-2 infection can be classified into five categories according to the severity of presenting symptoms as shown in Online supplement 2.

There is an increasing proportion of asymptomatic SARS-CoV-2 infections being described globally. 12 Patients who test positive for SARS-CoV-2 infection with no or mild symptoms at baseline are expected to have a shorter time to recovery than those with more severe symptoms. 13 In contrast, severely ill SARS-CoV-2 patients requiring high-flow nasal oxygen (HFNO), non-invasive ventilation (NIV), or invasive mechanical ventilation during their hospital stay have been shown to have extensive lung diffusion impairment at follow-up 6 months after illness onset. (Online supplement 2) 14 The American Society of Anesthesiology (ASA) and Anesthesia Patient Safety Foundation (APSF) developed a joint consensus on the suggested waiting time before surgery for COVID-19-recovered patients utilizing both symptoms-and severity-based categories as follows: [click here] 15 -Four weeks for an asymptomatic patient or recovery from only mild, non-respiratory symptoms.

-Six weeks for a symptomatic patient (e.g., cough, dyspnea) who did not require hospitalization.

-Eight to 10 weeks for a symptomatic patient who is diabetic, immunocompromised, or was hospitalized.

These timelines should not be considered definitive; each patient's preoperative risk assessment should be individualized, taking consideration of surgical intensity, patient comorbidities, and the benefit/risk ratio of further delaying surgery.

The number of newly diagnosed patients with lung cancer in the United States decreased by 91% in the period from March to April 2020 when compared to the same period in 2019, 16 indicating the negative impact of national lockdowns and restrictions on seeking healthcare advice including lack of outpatient clinics and access to diagnostic tests (e.g. computed tomography (CT) scans, positron emission tomography (PET) and bronchoscopy).

Measures aimed at increasing health care capacity for COVID-19 patients were implemented after a notable 60% decrease in cancer-directed surgery in Canada. 17 The reduction in cancerrelated surgery has two explanations, first, the delay in new cancer diagnoses, and second, delays due to cancellation in light of overburdened health care resources. These delays can negatively impact the care and outcome of cancer patients. These hard lessons illustrate the need for careful consideration of delaying lung cancer surgery in infected patients with SARS-CoV-2.

Although delaying lung cancer surgery for >7 weeks in patients infected with SARS-CoV-2 might be advantageous allowing better preoperative preparation including prehabilitation, nutrition, and correction of anemia, it could also be associated with a deterioration in oncological outcomes. Thoracic surgical and oncological boards have published specific guidelines to triage elective cases considering urgency of procedure, potential alternative treatments and the burden of patients with COVID-19 on hospital resources. 1 The US National Comprehensive Cancer Network (NCCN) recommends scheduling elective cancer resection within 8 weeks following completion of clinical staging to prevent upstaging if the burden of local COVID-19 cases is low. In contrast, delaying curative surgery beyond 8 weeks is acceptable and associated with similar long-term outcomes if the burden of COVID-19 is high. 2 Importantly, suspected tumors with low malignant potential (adenocarcinoma-insitu, minimally-invasive adenocarcinoma or ground-glass opacities), can safely be deferred with imaging to reassess for progression at three to 6-monthly intervals. 18, 19 We recommend multidisciplinary team discussion to define the optimum timing of lung cancer surgery with consideration of vaccination status, 20 history of SARS-CoV-2 infection, and results of preoperative screening for SARS-CoV-2 disease.

Several published reports demonstrate persistent and prolonged symptoms and sequelae after SARS-CoV-2 infection affecting a range of body systems. These are summarized in Table 2 .

Careful preoperative evaluation to identify the presence of post-COVID-19 sequelae might help to individualize the optimal timing of thoracic surgery.

It is preferable for hospital organizations to have separate perioperative pathways for non-COVID-19 and COVID-19 positive patients, 21 though this is not always feasible in some regions.

In general, every patient should be screened clinically and virologically for SARS-CoV 2 infection by pharyngeal or nasal swab prior to surgery. [click here] 22, 23 Testing should be performed as close to surgery as possible (preferably less than 48 hours, not exceeding 5 days) to decrease the risk that a patient becomes positive while waiting for the surgical procedure. 24 -If an adult has a new exposure to a person with suspected or confirmed SARS-CoV-2 infection and meets the first two above criteria but has or develops new symptoms consistent with SARS-CoV-2 infection within 14 days of the new exposure, consultation with infectious disease or infection control experts may be necessary.

-If an alternative cause of the symptoms cannot be readily identified, retesting for SARS-CoV-2 infection may be warranted.

The WHO defines telemedicine ‗‗as the provision of healthcare services via the use of communication technology for the diagnosis and treatment of diseases and for continuing education of healthcare providers‖. Utilization of secured internet networks and video cameras has allowed specialists in distant geographic locations to perform complete clinical and physical examinations. 26 During the COVID-19 pandemic, there was a substantial increase in telemedicine use across the specialty of thoracic surgery. 27 Similarly, the ASA recognizes that many anesthesiologists may have increased or explored the use of telehealth Table   3 ] (Online supplement 1) Ideally, the operating or dedicated anesthesia room should be an -isolated‖ negative pressure room with >12 air changes/hour. Only half of the 198 respondents to an unpublished survey from the EACTAIC-Society of Cardiovascular Anesthesiology (SCA) reported that they have a negative-pressure room at their facilities, 43% of the half that have negative pressure rooms have just one to five negative-pressure rooms. This highlights the importance of our preliminary recommendations for practice in circumstances where a negative pressure room is not available:

-The level of Personal Protection Equipment (PPE) should be increased (e.g., respirators in place of masks, face shield or helmet).

-Alternatively, intubation can be performed in a negative pressure room followed by transfer to the OR, such as in an isolation ward or intensive care unit (ICU). The benefits of such an approach however need to be judged against its disadvantages and possible complications.

-In rooms with positive pressure, the room can be put under the least possible positive pressure with the rest of the surrounding unit under higher positive pressure, and the doors kept closed, so that the high exchange rate of air in operating theatres limits dispersion of aerosols outside the theatre, despite the positive pressure.

The operating room temperature level should be reduced to 18-20 degrees Celsius 29 and humidity kept between 40% and 60% 23, 30 A closed system for tracheal and endobronchial suction should be used. 23 Displays of laryngoscopes, bronchoscopy, and anesthesia machines, computers, anesthesia trolley, etc., could be covered with disposable transparent plastic sheets. 23 The breathing circuit should be checked as is standard practice. Antiviral filters like highefficiency particulate air (HEPA) or heat and moisture exchanger (HME) filters should be attached between the face mask/tracheal tube and the Y-shaped connector, and at the expiratory outlet of the breathing circuit. The CO 2 sample line should remain near the Yconnector but be situated on the ventilator side of the filter to avoid contamination.

-Medical staff involved in tracheal intubation should be limited to those with essential roles.

-We recommended previously not to include anesthesiologists at high-risk for COVID-19 infection such as those of older age (> 60 yrs.), immunosuppressed, pregnant, or having serious chronic co-morbidities [click here], in the intubating team. We acknowledge however this may not be practical during subsequent waves of the COVID-19 pandemic because of staff shortage, particularly with the need for quarantining of staff exposed to infected patients, and an anticipated increased volume of surgical cases after widespread cancellation of elective surgery during the first wave. We recommend however having personal discussions within work units to make appropriate decisions on the involvement of high-risk individuals in teams operating on patients with suspected or diagnosed infection with SARS-CoV-2. 23 -The previous recommendation of having two attendants in the -red zone‖ inside the operating room and a second doctor to help administer drugs and monitor the patient, and to be available in case of unanticipated difficulty is not supported by any evidence so far. 1 Additionally, this criterion is probably also not practical to achieve in many centers. There must however be a -runner‖ physician available directly outside the room in -yellow zone‖ with full donned personal protection equipment (PPE), in case of need for help. Though it is desirable to have an observer outside the dedicated OR -white zone‖, to monitor the PPE -donning/doffing‖ processes this may also not be practically possible at many centers particularly out-of-hours with limited staff numbers available. The surgical, anesthesia, nursing and paramedical staff who are not involved with airway management should not enter the operating theatre until after the airway has been secured.

-Staff turnover within the OR should be minimized (i.e., the same anesthesia personnel should remain in the operating room for the entirety of the case, if possible). 23 -A stepwise approach reproduced from the CDC's interim operational consideration is recommended for preoperative screening of patients undergoing thoracic surgery. In light of perceived shortages of N95 and FFP masks occurring during the multiple waves of SARS-CoV-2 infections, we acknowledge that in some centers, re-sterilization and reuse of these masks might be needed. 31, 32 We recommend fit testing for masks which are being used.

The majority of health care workers are vaccinated in many countries. Nonetheless, the task force recommends exercising the same precautions surrounding PPE use even in vaccinated staff because the protective effects of different vaccines are not yet proven.

Providing perioperative care to patients with SARS-CoV-2 infection for long periods whilst wearing PPE is challenging and emotionally demanding. There is a high prevalence of burnout among health care workers during the COVID-19 pandemic. 33 In a survey including 5030 healthcare workers in the US health system, the challenge of providing childcare for participants with children was repeatedly highlighted. Females with children were identified as being at increased risk of needing to leave the workforce and / or reduce hours. 34 Psychological counseling should be available (virtually if possible) to support the emotional health of staff [click here]. 23, 35, 36 Anesthesiologists are vulnerable to experiencing contact dermatitis, erythema, maceration, and fissures from prolonged use of occlusive gloves, frequent hand cleansing, and repeated use of alcohol-based hand gels. 37 Staff should consider their hydration and use of the toilet before starting the long cases. 23 Staff should be given appropriate break times between cases. 23 Additional urgent cases may be best performed by a new team if possible. 23 Attention should be paid to the environmental safety of restrooms and restaurants in hospitals to allow physical and psychological relief of the staff during break times. Several strategies can reduce the risk of exposure of staff to the risk of SARS-CoV-2 infection such as using 

The vaccine itself may result in some systemic effects, such as fever and chills, in the first 1-2 days following vaccination, but these symptoms generally resolve soon after; it has been reported these normally settle completely within a week. Such fever is uncommon after the first dose but occurs in about 15% after second dose. [click here]

There are reported findings of venous thrombosis and thrombocytopenia 5 to 16 days after vaccination 40, 41 ; it should be kept in mind that there is minimal experience about the unwarranted effects of different vaccines. These adverse effects and complications could however affect the outcome of any surgery.

We advise waiting for three weeks after vaccination before undergoing elective surgery, both to avoid diagnostic confusion regarding the cause of any symptoms such as fever which may be attributed to the consequences of either vaccination or the surgery itself, and also to permit a sufficient time for antibody formation. 42 At this time, it is not clear how long optimal protection lasts following vaccination, the authors recommend that the optimal timing of surgery post vaccination would be between 3 and 8 weeks. 42 Further studies are needed to support these recommendations.

Any waiting period for surgery (after either the infection or the vaccination) should be used to facilitate sufficient preparation and -prehabilitation‖.

Thrombosis prophylaxis using a ‗standard' prophylactic dose of enoxaparin (40 mg/day) under anti-Xa activity monitoring is recommended for acutely and critically ill hospitalized patients with SARS-CoV-2 infection. 23, [43] [44] [45] In the absence of bleeding, the strict application of thrombosis prophylaxis is recommended for all suspected or diagnosed SARS-Co-V-2 patients following surgery. 23

Our previous recommendations discussed the standard contents of the intubation trolley, which should be prepared in order to achieve safe and successful airway control and establishment of controlled ventilation without compromising the high-risk patient, and whilst providing maximal protection to the health care team. 1 We again recognize that some of the materials, devices, and drugs cited here are not available in some countries and centers. In this case, these recommendations should be read as a pathfinder to adapted guidelines. It is also a risk period for patients with severe COVID-19 who may not tolerate long periods of apnea or inadequate oxygenation in case of delayed or failed tracheal intubation.

-An elective intubation should be preferred, if possible, as emergency intubation may compromise protective procedures and could also increase the patient's risk.

-Tracheostomy should be considered in COVID-19 patients when prolonged mechanical ventilation is anticipated. However, there is insufficient evidence for recommending a specific timing for tracheostomy. 48, 49 We recommend leaving the decision on the relative merits of open versus percutaneous tracheostomy to the physician's discretion and institutional experience. 50 -Intubation and tracheostomy should be performed by the most experienced physician to minimize delay or related complications.

-Preparation: These recommendations have been outlined in the previous article. 1 Since its publication, there have been some changes, such as recommendations that barrier enclosures should not be used as a substitute for adequate PPE until validating their efficacy and safety in future studies. 51, 52 -Preoxygenation: 53  Appropriate preoxygenation is crucial as it can prevent / decrease the need for mask ventilation before securing the airway.  The pathway for dealing with an unanticipated difficult airway in thoracic anaesthesia is similar to that of general airway management. 11  The ETT cuff or the cuff of the tracheal lumen of the DLT should be inflated to seal the airway before starting ventilation and the depth should be noted and recorded. The cuff pressure should be kept at least 5-10 cmH 2 O above the maximum airway pressure using an inflatable manometer. This is to ensure adequacy of cuff seal and minimize the risks of aerosol generation.

-Double-lumen tube (DLT) or bronchial blocker (BB) 1 The attending anesthetist should be aware of the indications for, and the differences between lung separation and isolation. 1 The majority of 362 respondents who completed the EACTAIC survey reported the use of DLTs with or without an embedded camera. Few respondents report using bronchial blockers or non-intubated surgery. There was no statistically significant difference in the use / preference for DLT or bronchial blocker between the period before and after the onset of the COVID-19 pandemic. [ Figure 2 ]

 Lung separation with a single-lumen endotracheal tube (ETT) and BB may be preferred particularly:

1. In patients already intubated (this approach would avoid the risk of aerosolization during tube exchange).

In patients with a difficult airway (a -difficult‖ airway for ETT can be even more difficult for DLT).

3. In patients with tracheostomy. 4 . In short procedures. 5 . In patients in whom mechanical ventilation will be continued in the postoperative period (to avoid the need for tube exchange at the end of the operation, which can be more difficult because of edema of the airways and be an additional mechanism of contagion).

 It is suggested to use an ET-tube swivel-connector with a valve. Before opening the valve of the swivel and introducing the bronchoscope, the anesthesia ventilator should be paused. If saturation is critical, preoxygenation can be performed in advance. During bronchoscopy, ventilation may be resumed, but it is important to ensure that the valve of the swivel fits snuggly enough such that there is no leakage. Otherwise, bronchoscopy should be performed during apnea.

The same procedure should be carried out when the bronchoscope is withdrawn from the tube. Other openings of the airway, e.g., suctioning, should also be performed under apnea.

 If a BB is to be used, the trachea of the patient should be intubated with the largest possible standard ETT to allow enough room for the insertion of both the bronchial blocker and the fiberoptic bronchoscope.

 Tracheal intubation should be confirmed with continuous waveform capnography.

 In cases intubated with ETT and BB, the position of the BB (and the tube) should be confirmed with a flexible bronchoscope (FOB) or an ETT with an embedded camera. We suggest using a disposable FOB to avoid contagion, if available. The authors strongly maintain the philosophy that fiberoptic bronchoscopy is a crucial part of thoracic anesthesia; if however a bronchoscope is not available at all, or it is preferred to avoid its use for any (mostly logistic) reason:

o DLT with an embedded camera can be used. tongue with a gauze pad as a local anesthetic is trickled into the pharynx can be considered. 53 However, procedures with a high risk of coughing, such as transtracheal or trans-laryngeal injection of local anesthetics, should be avoided. 53  Supplemental oxygen can be delivered using face masks that allow endoscope passage (e.g., endoscopy mask), use of low or high flow nasal cannula, and via bronchoscope adaptors during the use of an intubation conduit (e.g., supraglottic device, channeled laryngoscope). 53  Titrated sedation with an infusion pump and close monitoring of the depth of sedation is essential. 53  For intubation, a flexible (preferably disposable) endoscope with a separate remote screen should be used. 53  Rescue intubation through an intubating supraglottic airway device or early front of neck access (FNAC) can be necessary and equipment should therefore be ready before the intubation attempt.

-After intubation  If necessary, a nasogastric tube can be placed, immediately after intubation.

 If the diagnosis of COVID-19 is suspected but not already confirmed, a deep tracheal aspirate for virology can be taken using closed suction.

 The patient should remain connected to the breathing circuit as much as possible.

A closed system with infra-glottic catheter tip should be used for suction. 57, 58 If a disconnection from the breathing circuit is inevitably necessary, the ventilator should be switched to stand-by, and the endotracheal tube should be clamped.

 After tracheal intubation, any airway equipment which has been contaminated, but which may be needed again during the procedure should be stored in the operation room in a designated box with a sign clearly indicating contamination.

After the surgical procedure, the equipment can be discarded or decontaminated appropriately. whole donning and doffing procedure should be repeated as described.

Patients with 'suspected' or 'diagnosed' with COVID-19 infection or those who are considered to still be infectious Volatile vs. total intravenous anesthetics.

The use of volatile anesthetics for sedation of ventilated patients infected with SARS-CoV-2 has been associated with a shorter duration of ventilation with improved gas exchange. 59 Volatile anesthetics might also have beneficial anti-inflammatory effects through their immune-modulating properties either by direct effects on immune cells or indirect effects on cellular protective pathways. 60 Interestingly, the 362 completed responses to the EACTAIC survey showed no statistically significant changes in thoracic anesthesia practice before and after the COVID-19 pandemic in terms of preference for volatile anesthetics, TIVA, or both techniques together. [ Figure 3 ]

We recommend leaving the choice of anesthetic for thoracic surgery to the decision and expertise of the practitioners using them until a supportive body of evidence is available.

A short survey for the opinions of the expert panel on the use of low flow volatile anesthesia showed no changes in practice compared to the period before the COVID-19 pandemic. Most of the respondents' report using a gas flow rate of 0.8 to 2 L/min and incorporating an antiviral filter into the breathing circuit.

The EACTAIC survey however showed no statistical difference between the use of nonintubated surgery before or during the COVID-19 pandemic [ Figure 2 ]. Although some guidelines for the management of other clinical conditions during the COVID-19 pandemic advocate regional anesthesia to avoid general anaesthesia and the need for airway management, we do not suggest this approach for thoracic surgery. Donning of the same level of PPE should be considered during regional anesthesia for infected patients with SARS-CoV-2 because the airway is left open to the room for the duration of the procedure with the associated risk of aerosol generation. [click here] There is no supporting evidence nor previous reports describing the use of the non-intubated technique in patients with highly contagious diseases. Intraoperative coughing and the risk of needing urgent intubation in a complex clinical scenario during non-intubated surgery are considered a contraindication to performing this technique during the pandemic in order to reduce the exposure of healthcare workers to droplet spread. 61 Even in the -healthy‖ (non Covid-19) population, non-intubated thoracic surgery is a novel, less well described approach, which contrary to some beliefs, is more challenging for the anesthetist. In the new clinical situation with the SARS-CoV2, there may be some exceptional cases that would benefit from this approach, but overall, it cannot be recommended.

It should be kept in mind that all techniques of non-invasive ventilation (NIV) are also associated with an increased risk of aerosol spread. Cautious use of NIV is therefore recommended, with full airborne level PPE donned and the patient cared for preferably in an isolated environment. There is currently no convincing evidence that HFNO increases the risk of cross-infection to healthcare workers. It is recommended therefore to weigh the risk/benefit ratio of using HFNO in patients with SARS-CoV-2 infection. 53, 62 Facemask oxygenation is likely to deliver better preoxygenation than NIV and HFNO, particularly for the difficult airway. 53, 62 

Patients with 'suspected' or 'diagnosed' with COVID-19 infection or those who are recovering or considered to still be infectious

Phenotype L: is characterized by (1) low elastance ‗normal compliance', (2) low ventilationto-perfusion (VA/Q) ratio, (3) low lung weight with only ground-glass densities present on CT scan located subpleurally and along the lung fissures, and (4) low lung recruitability because of the very low amount of non-aerated tissue. 63 Phenotype H: is characterized by (1) high elastance ‗low compliance' due to increased edema, (2) high right-to-left shunt due to the fraction of cardiac output perfusing the nonaerated tissue, (3) high lung weight (> 1.5 kg) resembling the acute respiratory distress syndrome (ARDS), and (4) high lung recruitability because of the increased amount of nonaerated tissue. 63 Reviewing the chest radiology can be helpful to define the needed ventilation settings. The chest CT scan is scored as having 0%, 25%, 50%, 75%, or 100% involvement, and the chest radiograph is scored as having opacities in one, two, three, or four quadrants. 64 Point-of-care ultrasound offers additional value in the clinical management of patients with SARS-CoV-2 infection. 65 There are two distinctive sonographic lung ultrasound (LUS) patterns to differentiate patients who may respond to high PEEP from those who would benefit from moderate PEEP.

-Pattern 1 shows diffuse or coalescent B-line artifact descending from the pleural line to the bottom of the scan sector without fade, moving in concert with the sliding pleura. This appearance is thought likely to be caused by local subpleural inflammation/interstitial edema (-ground-glass‖ lesions) on CT and correlates with the -L phenotype‖ described by Gattinoni et al. 63 Using moderate levels of PEEP (8-10 cmH2O) and higher tidal volumes (7-8 mL/kg predicted body weight) would be an appropriate initial strategy for those patients with preserved respiratory system compliance. In contrast, high PEEP levels of 10 to 15 cmH 2 O or alveolar recruitment maneuvers could lead to overdistention and cardiovascular instability.

-Pattern 2 shows significant basal consolidation in the posterior lateral zone referred to as "lung hepatization‖ due to extensive atelectasis or a pneumonic process, and signs of aeration in the anterior zones. This pattern resembles the -H phenotype‖ which may benefit from higher levels of PEEP.

-The reports about -different patterns‖ or -different phenotypes‖ should alert the anesthesiologist to identify the patient's respiratory condition and subsequently decide about the appropriate conduct of intraoperative mechanical ventilation. One of the most important conclusions of these reports should be that COVID-19 has different pulmonary characteristics in clinical practice.

During one-lung ventilation, another HEPA or HME filter should be applied to the end of the DLT lumen corresponding to the operative lung, which is disconnected during one-lung ventilation.

Other techniques have been suggested to isolate the lumen to the operative lung from the operating theatre environment such as applying a continuous suction or a sealed empty surgical glove. This might avoid (or decrease) the risk of aerosolization through the disconnected lumen ( Figure 4 ). This is probably one of the most important and avoidable risks of thoracic anesthesia in SARS-CoV-2 patients.

As the oxygenation of SARS-CoV-2 patients is already compromised, one-lung ventilation could be more challenging, and a higher incidence of hypoxemia during one-lung ventilation might be expected.

Generic recommendations for the conduct of one-lung ventilation (OLV) using lungprotective ventilation can also be considered valid in these patients: 49 -Volume-controlled or pressure-controlled ventilation. 64 -The authors avoid suggesting a FiO 2 of 1.0; instead, we suggest applying the most appropriate to ensure normoxia, as both hypoxia and hyperoxia can be harmful, especially in a critical case.

-Low tidal volume 4-6 ml/kg predicted body weight.

-Some degree of hypercapnia can be permitted by adjusting the respiratory frequency (pH kept above 7.2).

-The required positive end-expiratory pressure (PEEP) will vary widely according to the respiratory system compliance. 64 -Patients may get benefit from the application of a ‗staircase' alveolar recruitment maneuver, 66 and a trial is recommended. It should be kept in mind however that any recruitment strategy can impair hemodynamic stability in a more extended way than in -healthy‖ patients. 49 Clearly in some patients with active lung disease, maintenance of OLV may be impossible due to oxygenation problems. In such cases it should be kept in mind that in cases without obligatory indications for lung -isolation‖ (e.g., airway leakage, unilateral bleeding), the price to continue the OLV must never be to compromise oxygenation. This general rule must be even more strictly adhered to in challenging cases such as SARS-CoV-2 patients.

If the application of CPAP is deemed necessary, we recommend incorporating an antiviral filter to the operative lung. 7, 9 In some cases, application of inhaled nitric oxide (iNO) or even extracorporeal assist systems (for oxygenation and/or carbon dioxide removal) can be indicated. These cases are beyond the scope of this review. era. 71 In VATS, carbon dioxide insufflation is not used so the risk of aerosol generation may be even lower than in laparoscopic surgery. Figure 5 in the previous version) 1

The authors assume that in almost all intubated SARS-CoV-2 patients requiring thoracic surgery, mechanical ventilation may need to be continued after the operation. However, they acknowledge that extubation should not be delayed for the risk of reintubation. 49 If a BB was used, it can simply be removed at the end of the operation.

If a DLT was used, it should be changed to a normal ETT under the guidance of a video laryngoscope 53 using an appropriate tube exchanger (Caveat: specific tube exchangers for DLT should be used). In such cases, regulations for PPE (donning and doffing) should be repeated step by step.

-Prior to extubation, aspiration via a closed system, followed by a recruitment maneuver is suggested.

-Patients should be ready for extubation on to facemask. Air flow to the surrounding area should be avoided as much as possible; a tight-fitting facemask is therefore essential.

-A mask over tube extubation is recommended. 72 The anesthesiologist positions the ETT or DLT to the side of the mouth closest to the assistant and places a face mask over the patients mouth and nose with a second antiviral filter using a two-handed technique to ensure a good seal. 72 Following deflation of the tube cuff, extubation is performed at endexpiration while maintaining the face-mask seal. 72 -Again, aerosolizing procedures (e.g., non-invasive ventilation (NIV), high flow nasal oxygen (HFNO), nebulizing bronchodilators) should only be used if needed to treat hypoxemia or bronchoconstriction after extubation, and should only be performed whilst donning the same level of PPE, conditions, and logistics, as applied during intubation. 62 -Any maneuver which risks precipitating coughing should be avoided: oral suctioning (if any) should be very gentle; patients should not be asked to cough. In difficult airway cases, using an extubation catheter (e.g., with a soft, thin tip) can be possible, but in these cases, keeping the patient intubated is more rational.

-Use of medication known to effectively lower the incidence of coughing (e.g., dexmedetomidine, lidocaine) and postoperative nausea and vomiting is advocated. 53 -Placing a surgical mask or N95 respirator on the patient whilst providing supplementary oxygen via face mask or nasal prongs after extubation could prevent hypoxemia and reduce risk of environmental viral spreading. 54 -Using a simple antiviral filter with bubbling chest drains is recommended to reduce inhospital spread of SARS-CoV-2. 73 -Intra-hospital transfer of extubated patients should follow local regulations.

Patients with 'suspected' or 'diagnosed' with COVID-19 infection or those who are considered to be still infectious -The breathing circuit should be changed.

-Airway breathing system (ABS) / anesthetic gas scavenging system (AGS) and soda lime canisters should be decontaminated.

-All disposable material should be discarded; reusable material should be sent for appropriate decontamination.

-A waiting period of 20 minutes is necessary prior to disinfection with 3% -5% chlorine solution.

Thirty-six percent of 343 respondents to the EACTAIC survey reported using thoracic epidural analgesia, 22% use paravertebral block, 16% use local anesthetic infiltration, and 11% use erector spinae block, and 11% use intravenous analgesia for thoracic surgery in their institutions before the COVID-19 pandemic. Interestingly, only 5% of the 415 respondents reported changing analgesic methods during the COVID-19 pandemic. We cannot recommend changes to institutional practice for perioperative analgesia and regional blockade in light of the lack of supporting evidence. However, we recommend following the recommendations of the Joint Statement by the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the European Society of Regional Anesthesia and Pain Therapy (ESRA). [click here] 74

The COVID-19 -pandemic‖ has undoubtedly become one of the most important challenges for the human race in recent memory. Health personnel will in all likelihood have to deal with a wide range of COVID-19 cases undergoing different operations.

Observing the changes that the -multiple waves of the COVID-19 pandemic‖ have already caused, we can foresee that -routine life‖ of daily practice in our hospitals becomes radically different, with all materials used for anesthesia potentially subject to shortage in time.

Though these -updated recommendations‖ have been prepared with expert opinions, unpublished results of the EACTAIC survey, and best evidence available to date, they cannot claim to be entirely -evidence based‖. Nonetheless, we hope that they can be helpful to our colleagues, not only for thoracic anesthesia but also to organize general management of this challenging patient group.

All authors declare no conlict of interest. with and without an embedded camera, or non-intubated surgery before and during the COVID-19 pandemic. X 2 test was used to compare data before and during the COVID-19 pandemic. P<0.05 represents a statistically significant difference. 

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