key: cord-0862303-2hqki937
authors: Fuchs, Alexander; Lanzi, Daniele; Beilstein, Christian M.; Riva, Thomas; Urman, Richard D.; Luedi, Markus M.; Braun, Matthias
title: Clinical recommendations for in-hospital airway management during aerosol-transmitting procedures in the setting of a viral pandemic
date: 2020-12-08
journal: Best Pract Res Clin Anaesthesiol
DOI: 10.1016/j.bpa.2020.12.002
sha: 6a23790643666f7fcd4ca4a03b864bf2957a49bc
doc_id: 862303
cord_uid: 2hqki937

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can lead to severe pneumonia and multi-organ failure. While most of the infected patients develop no or only mild symptoms, some need respiratory support or even invasive ventilation. The exact route of transmission is currently under investigation. While droplet exposure and direct contact seem to be the most significant ways of transmitting the disease, aerosol transmission appears to be possible under circumstances favored by high viral load. Despite the use of personal protective equipment (PPE), this situation potentially puts healthcare workers at risk of infection, especially if they are involved in airway management. Various recommendations and international guidelines aim to protect healthcare workers, although evidence-based research confirming the benefits of these approaches is still scarce. In this article, we summarize the current literature and recommendations for airway management of COVID-19 patients.

. Aerosol-generating procedures (AGP) identified by the US Centers for Disease Control and Prevention [26] and odds ratios (OR) for the risk of SARS transmission for healthcare workers exposed vs. not-exposed to SARS (Tran et al. [23] )

Tracheal intubation and extubation 6. Abbreviations: SARS: severe acute respiratory syndrome

The risk of transmission or infection is increased for healthcare workers during aerosol-146 generating procedures (AGPs) [7, 27, 23] due to the high virus concentration in the patient's 147 upper airway and sputum [28] . Protection of workers involved in airway management must 148 be a high priority, and personal protective equipment (PPE) should be available for the whole 149 team involved in treating suspected or confirmed COVID-19 patients. To minimize the risk of 150 multiple transmissions, the number of healthcare personnel involved in an aerosol-generating 151 procedure should be reduced to the minimum, while maintaining the patient's safety at all 152 times. All of these procedures are best performed in rooms with negative pressure or with air 153 exchange rates of up to 6-12 times per hour [29, 12, 13] . Some authors even suggest 154 avoiding rooms with positive pressure (e.g., operating rooms (OR) for airway procedures 155 [13] . However, the recommendation seems to be difficult to apply due to lack of availability of 156 emergency rooms (ERs), ORs and intensive care units (ICUs). A preoperative huddle 157 consisting of all staff involved in the care of the patient is important to improve teamwork and 158 reduce unnecessary exposure [30] . 159 160

A severe COVID-19 infection can lead to acute respiratory failure and therefore requires 162 emergency intubation. Such patients are characterized by very high viral spread [31] . The 163 point at which intubation is indicated may differ from institution to institution and also may be 164 influenced by the existing resources in an acute pandemic situation, such as the availability 165 of beds with mechanical ventilation and ICU care, or the possibility to relocate an intubated 166 J o u r n a l P r e -p r o o f patient. Evidence is lacking with regard to the best time for intubation, but the current 167 recommendations tend to avoid emergency intubation of unstable patients, instead providing 168 early intubation in order to protect the involved employees [32, 13, 12] . Adapting an 169 institution's existing airway management algorithms to the pandemic situation seems to be 170 the most appropriate approach, due to prior experience and high acceptance [13, [33] [34] [35] [36] [37] . 171

Some published consensus guidelines [12, 21, 13] suggested the creation of dedicated 172 intubation teams. These teams should be composed of an experienced airway manager and 173 1-2 assistants per patient, regardless of whether COVID-19 is confirmed or suspected. 174

Reducing the number of potentially exposed persons and the exposure time during an AGP 175 can potentially shorten workers' exposure to a high viral load and could be one of the keys to 176 minimizing new infections. Team members should be familiar with the airway tools, 177 monitoring equipment, ventilators and drugs used to safely perform tracheal intubation. 178

Simulation training of airway management and PPE can significantly increase adherence to 179 standards and therefore the safety of patients and healthcare providers [21] . The method of 180 communication has to be established before the procedure starts, and should result in an 181 "airway plan". Clear the procedure for every team member, and try to communicate directly 182 and in a closed-loop manner, both within your team and with any teams from other 183 disciplines [12] . 184

Preoxygenation should be performed for 3-5 minutes [32, 17, 38] with a good sealed mask 185 and rapid sequence induction [12] . There is evidence of decreased desaturation rates with 186 low-flow apneic oxygenation (oxygen 1-5 l/min) provided by a conventional nasal cannula 187 during intubation [39, 40] . Although strong evidence is lacking, it seems unlikely that such 188 procedures produce a relevant amount of aerosol [12] . There is a strong consensus that 189 video laryngoscopy (VL) should be preferred [13, 29, 12] as it offers some distance between 190 the healthcare professional and a potentially extremely high virus load in comparison with 191 direct laryngoscopy (DL) [31] . In patients with a difficult airway, VL improves glottic view, 192 reduces airway trauma [41] and can increase first-pass intubation success [42] . In general, 193 the use of a standard blade is recommended, with a hyperangulated blade as a backup. The 194 choice of equipment should always be adapted to the skill and clinical judgement of the care 195 provider performing airway management [13] . In case of the unavailability of VL or 196 unfamiliarity with this tool, well-known standard procedures should be performed instead of 197 experiments with unfamiliar ones [33, 12] . 198

Practicing rapid sequence induction (RSI) in patients with very limited pulmonary function 199 and almost nonexistent respiratory reserve is already challenging. In this context, induction 200 medications with rapid effect and a deep neuromuscular block to suppress coughing should 201 be mandatory. The recommendations for neuromuscular blocking agents (NMBAs) favor 202 rocuronium [12] in a dosage between 1.2 mg/kg and 1.5 mg/kg ideal body weight (IBW) [13] 203 and sugammadex available in case of an unexpected difficult airway [43] . If succinylcholine is 204 used as the NMBA, the recommended dosage is 1 mg/kg [43] up to 1.5 mg/kg total body 205 weight (TBW) [12, 13] . An international consensus on how to perform rapid sequence 206 induction is still lacking [44] . 207

Induction of anesthesia for intubation exposes the patient to an increased risk of 208 hemodynamic instability or even cardiac arrest. In patients susceptible to significant 209 hemodynamic fluctuations, consider ketamine at a dosage of 1-2 mg/kg for a 210 hemodynamically stable induction and have vasopressors ready to use during the intubation 211 phase [12] . An easy way to administer norepinephrine in such situations is 10 mcg/ml as a 212 push dose. 213 214 A common concern of healthcare workers which should be taken into consideration is that 215 massive exposure to COVID-19 can occur during intubation. A recent study showed that 216 tracheal intubation-including facemask ventilation-produced rather low quantities of 217 aerosolized particles compared to extubation and much less than a coughing patient [45] . 218 Therefore, there is strong agreement that coughing should be avoided whenever possible. 219

This underlines the importance of a deep neuromuscular block during airway procedures. 220 J o u r n a l P r e -p r o o f After intubation the cuff should be inflated immediately and a viral filter should be connected 221 at the end of the tube before starting positive pressure ventilation [13, 12, 29] . Expiratory 222 capnography has to be monitored continuously [12] . Auscultation of the chest can be 223 challenging when wearing a full PPE, and provides a potential risk of contamination; 224 therefore it may not be feasible. If correct placement of the tube needs to be verified, a chest 225 radiograph should be considered after potential central lines or catheters have been installed 226 [13] . Alternatively, point-of-care ultrasound (POCUS) [46] can be used to assist in determining 227 endotracheal tube depth and to rule out a pneumothorax, if needed [29] . 228 229

Nowadays, careful bag-mask ventilation is acceptable while performing a rapid sequence 231 induction [47] . Nevertheless, as a recognized aerosol-generating procedure it should be 232 avoided whenever feasible in suspected or confirmed COVID-19 patients, unless it is a 233 rescue maneuver to treat an unexpected difficult airway [48, 13, 29] . 234

These patients present with a higher risk of hypoxia, and mask ventilation should be 235 considered in some cases [10] . If indicated and applied, sealing of the mask is crucial, and a 236 filter needs to be placed directly after the mask to minimize the dispersion of aerosols. To 237 achieve a good seal, the two-handed V-E grip [49] can be used with a two-person-technique. 238

Oropharyngeal airways such as Guedel's or Wendel's may be used to ensure an open 239 airway [50] , and minimal positive pressure and low oxygen flow should be applied. 240

Monitoring the bag-mask ventilation with continuous wave capnography is important in order 241 to detect possible leaks [51] . Some authors suggest placing two wet tissues between face 242 and mask to achieve a better seal [43] , but there is no evidence supporting this technique. If 243 it is not possible to achieve a good seal with the mask, and careful ventilation seems 244 unattainable, a supraglottic airway device (SAD) should be inserted. This is considered to be 245 safer and produces less aerosol [13] . 246

If disconnection of the tracheal tube of an intubated patient is necessary, proper preparation 249 helps to minimize the amount of aerosol generated and the amount of time it takes to 250 disperse. To help avoid a coughing patient, consider deep sedation and profound muscle 251 relaxation before the procedure starts. If no direct access to the airway is necessary, the 252 tracheal tube should be clamped between the filter and the patient after the patient has 253 inhaled, in order to maintain the positive end expiratory pressure (PEEP) generated and 254 therefore to avoid atelectasis during this maneuver [12] . Open suctioning, bronchoscopy, and 255 disconnection of the ventilator circuit should be avoided unless necessary, since these can 256 generate aerosols. If possible, a closed suctioning system should be installed [52, 43] . 257 258

Extubation is considered a high-risk AGP due to the high likelihood of coughing and possible 260 agitation while the endotracheal tube is being removed. Extubation produces up to 15 times 261 more aerosols than intubation [45] . A number of techniques have been developed to reduce 262 aerosol production and droplet spread during extubation. Physical protection-such as 263 consequent use of PPE and early application of a surgical mask to the patient's face-seems 264 to best protect staff from being contaminated [53, 54, 12] . The number of healthcare workers 265 involved should be reduced to the minimum. Extubation under deep sedation is not 266 recommended due to possible absence of spontaneous ventilation, prolonged time with an 267 unsecured airway, increased risk of aspiration and therefore increased risk of requiring bag-268 mask ventilation and re-intubation. Medications suppressing coughing, such as opioids, 269 lidocaine or dexmedetomidine, may be considered as preventive measures [55] [12, 13] . 270

Indications for non-invasive ventilation (NIV) in patients with acute respiratory distress 273 syndrome (ARDS) or COVID-19 are beyond the scope of this review. In general, NIV and 274 humidified application of aerosolized (nebulized) medications should be avoided [13, 29] in 275 aerosol-transmitted viral diseases, to protect healthcare workers until evidence is available 276 from randomized controlled trials. A review article published in 2014 in the context of 277 influenza A H1N1 reported transmission to staff caring for patients treated with NIV in one 278 study out of 22 [56] . A recently published review article reports that the risk of transmission of 279 COVID-19 to healthcare workers may be increased [57] . However, if NIV is used, it is 280 recommended that the treating practitioners wear full PPE and that isolated areas be used to 281 protect the staff and other patients [13, 29] . 282 283

It still remains unclear if and how much aerosol is generated by inserting-and removing-a 285 SAD [33] . If a SAD is leaking or patients are coughing at its removal, it is very likely that 286 aerosols will be generated. In the management of an airway due to pulmonary exacerbation 287 in symptomatic COVID-19 patients who will be intubated anyway for long-term ventilation, 288 SAD might play a role as a rescue tool in an unanticipated difficult airway. If one is using 289 SAD for general anesthesia, the provider should keep the risk of the AGP in mind. The leak 290 may be smaller with a spontaneously breathing patient, but if the anesthesia is too "light" 291 there may be an increased risk of coughing [33] . A SAD of the second generation is believed 292 to produce less aerosol than bag-mask ventilation [13] . 293

The use of high-flow nasal cannulas (HFNCs) is controversial. A retrospective analysis by 296

Patel et al. [58] postulated that they reduce the incidence of intubation and lead to better 297 outcomes in the case of severe COVID-19 infections. Some earlier randomized controlled 298 trials have shown benefits of high-flow nasal cannula therapy in the context of acute 299 respiratory failure-caused by pneumonia and without hypercapnia-compared to 300 conventional oxygen therapy to prevent NIV and invasive mechanical ventilation [59, 60] . 301

Nevertheless, in some cases necessary intubation may be delayed [12] . These findings have 302 not been decisively demonstrated [61] [62] [63] . 303

Although the use of HFNCs is highly suspected of generating aerosols, the amount still 304 remains unclear, and is thought to be smaller with newer models [12] . As HFNCs are on the 305 list of aerosol-generating procedures [64] , there might be an increased risk of significant 306 aerosol exposure for healthcare workers, even if there is low evidence. Instead of completely 307 banning the cannulas, however, hospitals should evaluate their risks and benefits [13, 33, 308 65] . There are differences between using HFNCs to avoid desaturation during airway 309 instrumentation or with the intention of delaying or preventing an intubation that could lead 310 patients to a long period of mechanical ventilation. 311

If the use of HFNCs is considered, it should be subject to the same safety precautions as 312

NIV. This means that the healthcare workers providing the treatment need to wear PPE, and 313 treatment should only be provided in areas with isolation of airborne particles [13] . In 314 addition, during a pandemic, there is a need to conserve resources as much as possible. In 315 fact, even oxygen supply may be scarce [12] , and the use of HFNCs may contribute to 316 depleted reserves. 317 318

In "can't intubate, can't oxygenate" (CICO) situations, a surgical emergency front-of-neck 320 airway (eFONA) created with scalpel and bougie may be preferred over a needle 321 technique [12] . Attempts to oxygenate via bag-mask ventilation during the procedure should 322 be avoided to minimize the risk of generating aerosols [13, 12] . 323

Tracheostomy is common for patients who need long-term ventilation, but it is considered a 324 high aerosol-generating procedure [66] . Even though there is evidence of better patient 325 outcomes in early compared to late tracheostomy [67] , those findings are not specific to 326 COVID-19 patients, and the best time to perform a tracheostomy in these patients remains 327

controversial. One taskforce recommended that extended endotracheal intubation be 328 considered in order to protect healthcare workers [68] , but a recent cohort study showed that 329 tracheostomy can be a safe procedure if performed by an experienced team wearing PPE 330 [69] . Deep neuromuscular blockade is recommended to prevent the patients from coughing 331 while tracheostomy is performed [70] . 332 333

Awake tracheal intubation (ATI) is a procedure performed on patients with expected or 335 known difficult airways [71] . It is usually performed with a flexible endoscope, but can also be 336 performed with video laryngoscopes [72] or rigid optics such as the C-MAC VS (Karl Storz, 337

Tübingen, Germany). ATI is an aerosol-generating procedure, which is performed while in 338 close proximity to the spontaneously breathing patient. 339

Due to reductions in elective surgeries in a pandemic situation, the clinical load of such 340 cases -more likely to be found in ENT surgery-will decrease [33] . Nevertheless, there will 341 be intubations for patients with an expected or known difficult airway, for those needing 342 emergency surgery, and for those needing intubation due to COVID-19 infection. 343

ATIs should only be performed if there is a strong indication and no other alternative is 344 deemed safe. Coughing should be suppressed as much as possible. This can be achieved 345 with topical anesthesia and short-acting intravenous opioids (e.g., remifentanil). Disposable 346 devices should be used if available, and the operator should be experienced in this technique 347 [17, 32] . Intratracheal application of local anesthetics should be avoided due to the cough 348 stimulus [33] . Some authors recommend primarily nasal intubation via an endoscopic mask, 349 and only switching to oral intubation in case of failure [17] . The authors of this review believe 350 that in a complex and difficult airway management situation, using the techniques and 351 materials one is most familiar with will be the most successful approach. 352

The choice of a small endotracheal tube reduces the cough generated during insertion [32] . 353

Unfortunately, a small tube causes more resistance and therefore generates increased 354 airway pressures. Especially for long-term mechanical ventilation of a COVID-19 patient with 355 ARDS, it seems to be more reasonable to have a rather large endotracheal tube. Some 356 authors suggest using an endotracheal tube size 7 or 8 for women and a size 8 or 9 for men 357 [12] . Both indication and possible duration-a short emergency operation vs. long-term 358 intubation-should be considered in advance. In the event of ATI failure, the ENT surgeon 359 should decide early on whether to perform a tracheotomy [17] . Although the application of 360

HFNCs is controversial (see above), ATI could possibly be a good indication. HFNCs may 361 allow deeper sedation and therefore lead to less irritation and coughing. Although staffing adjustments that focus on epidemiological factors may reduce this shortage 366 [73] , keeping healthcare workers healthy and safe must remain a central concern. 367 Availability and use of personal protective equipment is key to protecting the healthcare 368 workforce. In general, staff members who are involved in airway management of a patient 369 with suspected or proven COVID-19 infection should follow available recommendations. This 370 includes correct hand disinfection and single-use airborne PPE, consisting of a mask 371 (whenever possible N95, KN95 or filtering face piece class 2 (FFP2) or higher), protective 372 goggles, a hat, a gown, and gloves (optionally 2 pairs); a practical overview was recently 373 provided by Cook et al. [74] . This protective gear should be worn for all airway-related 374 procedures, as well as while caring for COVID-19 patients [12, 13, 29] and especially during 375

Of equal importance is the procedure to be followed when doffing the PPE, as errors are 377 associated with a potential risk of infection. Simulation of donning and doffing can improve 378 safety in handling [75, 12] , as can a "buddy system" with checklists followed by a specialized 379 supervisor for donning and doffing PPE [12, 13] . At the very least, supervision of the removal 380 process should be introduced, and proper hand hygiene after removal is mandatory [29] . 381

Additionally, the environment should be decontaminated for at least 20 minutes [12] after 382 AGP or depending on the air exchange capacity of the room. The virus can be detectable for 383 up to 72 hours, depending on the surface material [20] 384

Children who test positive are often asymptomatic (18-22%) or present with mild symptoms 387 like fever and general respiratory symptoms [76, 77] . Hospitalizations and intensive care unit 388 admissions are rare [78] . 389

We will briefly discuss the challenges to be considered when anesthetizing children in the 390 specific context of the COVID-19 pandemic. As in cases involving adults, protection of 391 healthcare workers should be prioritized, with no exceptions, and PPE must be worn for all 392 risky procedures. 393

There are some precautions to be taken preoperatively that could differ from the daily routine 394 of a pediatric anesthesiologist. Because inhalational induction increases the risk of exposure 395 to respiratory droplets and aerosols, intravenous induction should be the first choice in the 396 case of COVID-positive children [79] . To reduce the child's anxiety as well as crying during 397 intravenous (IV) line placement, the administration of premedication combined with patches 398 for topical anesthesia of the puncture site is highly recommended. Because of the risk of 399 sneezing or coughing, nasal premedication should be avoided and oral or rectal 400 premedication should be preferred [16] . To minimize the potential risk of transmission of 401 SARS-CoV-2 to staff and to preserve PPE, during induction the presence of parents who 402 have close contact with the child (and are considered potentially infected) is not 403 recommended. Nevertheless, if the parents are asymptomatic and wearing correct PPE, this 404 may be adapted to the specific situation, because a calm child with parents is safer than an 405 agitated, crying and coughing child [16] . The parents should leave before any aerosol-406 generating procedure starts. 407

As in the case of performing anesthesia for an adult patient, endotracheal intubation (sealing 408 of the airway) with a VL using a modified RSI should be performed, and low-flow nasal 409 oxygen with a conventional cannula for apneic oxygenation (e.g., 0.2 l/kg/min) should be 410 considered during the procedure to prolong the time until desaturation and to increase safety 411 [80] . For the same reason, due to the risk of extreme desaturation during airway 412 management, the classical RSI technique should not be performed. In this case, the mask 413 should be kept sealed to minimize aerosolization. To minimize the duration of intubation and 414 the number of attempts needed, the use of apneic oxygenation should be considered and the 415 most experienced person should perform the laryngoscopy. In addition, a cuffed 416 endotracheal tube should be used whenever the situation allows and the weight of the child 417 is over 3 kg. In a situation where the placement of an IV catheter is difficult and the child is 418 agitated and combative, exposure to respiratory droplets may increase considerably. In this 419 case, we recommend an ultrasound-guided venous puncture to facilitate venous access or 420 an inhalational induction with the precaution of keeping the mask sealed and using the 421 lowest possible flow rate [16] . HFNC can be useful in elective endoscopic airway surgery 422 procedures [81] , but should be carefully evaluated as it is potentially an AGP. Anesthesia can 423 be maintained following institutional routine. Emergence from anesthesia in deep sedation is 424 indicated to minimize dispersion of droplets due to coughing [82] ; children with confirmed or 425 potential COVID-19 should be extubated before leaving the operating room to avoid a stay in 426 the pediatric post-anesthesia care unit [16] . Children who require a postoperative stay in the 427 pediatric intensive care unit (PICU) should be extubated in the PICU. 428

In situations where a difficult airway is encountered, the principles already mentioned for the 429 airway should be applied. In addition, task fixation and prolonged attempts at intubation 430 should be avoided in order to avoid increased aerosolization of the virus. In children with 431 COVID-19 the first choice for intubation is videolaryngoscopy. In case of failure, an early 432 change to more advanced intubation techniques such as intubation via fibroscopy through 433 SGA is desirable. In addition, even for children with COVID-19, anatomical and functional 434 airway obstructions must be recognized and treated in order to avoid CICO situations [83, 435 16] . In very rare cases these situations can degenerate and a surgical airway will be 436 required [84] . 437 eFONA in children is very rare and is associated with poor outcomes [85] . As in adults, a 438 surgical eFONA with scalpel is recommended: in the absence of an ENT surgeon, rapid 439 sequence surgical tracheostomy should be preferred to access the trachea for emergencies 440 in children under 8 years of age [86] . For children older than 8 years, we prefer a scalpel 441 bougie technique over a needle technique [87, 88, 86] . There are no other special made of a variety of materials (mostly plastic) were tested and used [33] [34] [35] [36] [37] , but there was 450 no validation and no randomized trials of these devices [89] . Systematic analyses do not 451 recommend the use of such tools, not only due to a lack of evidence, but also because most 452 of them have proven to be ineffective, impeding a rapid intubation through delays and 453 making airway management unsafe [90] . In fact, the concentration of aerosol in the 454 containment box could even be higher than without it, exposing the airway manager to a 455 greater risk of infection [91] . Reviews published until now therefore suggest avoiding the use 456 of protective aids and focusing more on correct handling of PPE and proper ventilation, 457 which workers are already familiar with in their daily practice [91] [92] [93] . protecting healthcare workers is a key goal. A summary of existing airway management 467 recommendations is presented in Table 2 . 468 Lowest gas flow n/a n/a n/a n/a n/a Adherence and 

In order to further improve safety during airway management, it is important to clearly define an aerosol-generating procedure (AGP), how much aerosol is produced during one, how performing an AGP affects healthcare workers, and how much workers are put at risk of infection. A range of measures are under consideration for use in treating COVID-19

patients, among them proper hand hygiene and correct donning and doffing of PPE;

simulation training for airway management involving PPE; the use of highly experienced "Airway teams" in which the person with the most experience performs the procedure;

preparation for situations with an unexpected difficult airway; and suppression of coughing in patients undergoing airway-related procedures.

It is important to protect both high risk patients and healthcare workers and not to experiment with new techniques and tools that could lead to increased exposures. As was true before the onset of COVID-19, any AGP without strong indications should not be performed.

The care of COVID-19 patients is challenging due to many factors, not the least the reduced capacity of beds, ventilators, and personnel. Institutional requirements and resources need to be evaluated before the airway management starts. Triage adapted to the individual institution and situation is useful and should be discussed in advance, especially in times of low capacity. Overall, preparation and planning are even more essential.

In this review we discuss the management of the airway and the precautions that need to be taken in detail, but just as important is the realization that our knowledge will evolve over time as we learn more about the COVID-19 virus. The pandemic is ongoing, and we will be confronted with it for a while.

• There is limited evidence for the impact of aerosol-generating procedures and their influence on infection in healthcare workers;

J o u r n a l P r e -p r o o f

• Airway preparation and management should be performed by experienced staff who do not belong to a high risk group;

• To avoid or suppress coughing in COVID patients, use a deep neuromuscular block and rapid-sequence induction for intubation and airway management;

• Hand disinfection and adequate PPE with a "buddy system" are essential for the protection of healthcare staff;

• Adapt and use algorithms and equipment that healthcare workers are already familiar with;

• Use simulation training-especially for airway management and usage of PPE-to improve adherence and safety.

• Define an aerosol-generating procedure (AGP),

• Better estimate how much aerosol is produced during an AGP,

• How performing an AGP affects healthcare workers,

• How much workers are put at risk of infection during AGP procedures,

• Most effective ways to protect healthcare workers

This research did not receive specific support from funding agencies in the public, commercial, or not-for-profit sectors.

Richard D. Urman reports research funding/fees from Merck, Medtronic/Covidien, AcelRx, Takeda, Pfizer. All other authors declare no conflicts of interest.

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COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study

Inhalational versus intravenous induction of anesthesia in children with a high risk of perioperative respiratory adverse events: A randomized controlled trial

Transnasal humidified rapid insufflation ventilatory exchange for oxygenation of children during apnoea: a prospective randomised controlled trial

Early experience with high-flow nasal oxygen therapy (HFNOT) in pediatric endoscopic airway surgery

Use of laryngeal mask airway and its removal in a deeply anaesthetized state reduces emergence agitation after sevoflurane anaesthesia in children

A framework for the management of the pediatric airway

Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis

A comparison of pediatric and adult anesthesia closed malpractice claims

Emergency front of neck access in children: a new learning approach in a rabbit model

Rescue oxygenation success by cannula or scalpel-bougie emergency front-of-neck access in an anaesthetised porcine model

The role of scalpel-bougie cricothyroidotomy in managing emergency front of neck airway access. A review and technical update for ENT surgeons

Measurement of airborne particle exposure during simulated tracheal intubation using various proposed aerosol containment devices during the COVID-19 pandemic

Protecting staff and patients during airway management in the COVID-19 pandemic: are intubation boxes safe?

Aerosol boxes and barrier enclosures for airway management in COVID-19 patients: a scoping review and narrative synthesis

Safe extubation during the COVID-19 pandemic

Intubation boxes for managing the airway in patients with COVID-19

None declared under financial, general, and institutional competing interests

None declared under financial, general, and institutional competing interests Christian M Beilstein: None declared under financial, general, and institutional competing interests

None declared under financial, general, and institutional competing interests

Declared research funding from Merck, Medtronic, Acacia, AcelRx and fees from Takeda and Heron

None declared under financial, general, and institutional competing interests

None declared under financial, general, and institutional competing interests

We thank Jeannie Wurz for her careful proofreading of this manuscript.J o u r n a l P r e -p r o o f