Indications and care during intubation and tracheostomy
Head and neck surgeons, otolaryngologists, maxillofacial surgeons and anesthetists are at high risk of contamination and infection by SARS-CoV-2 when assisting patients with tracheostomy or performing a rhinoscopy or a laryngoscopy because of the generation of aerosols. Fortunately, tracheostomy is unlikely to be required for the majority of patients. All patients must be examined by a physician wearing PPE such as N95 or FFP2 mask or PAPR, gown, cap, eye protection and gloves.828 For a tracheostomy, all staff must keep PPE with a powered air-purifying respirator (PAPR) throughout the procedure.11
The Royal College of Surgeons has posted guidance for surgical tracheostomy during the COVID-19 pandemic (https://www.entuk.org/tracheostomy-guidance-during-covid-19-pandemic), with advice as to decreasing the risk of aerosolization: stop ventilation while the tracheostomy window is being performed, and only resume ventilation when the cuff of the tracheostomy tube has been inflated.
Zuo and co-workers presented the Chinese Society of Anesthesiology Task Force on Airway Management recommendations for proper practice of tracheal intubation by frontline anesthesiologists and critical care physicians in critically ill patients with COVID-19 disease.36 Intubation is considered a high-risk procedure due to the physician exposure to secretions, blood, droplets and aerosols and should be indicated only for patients with severe respiratory distress or hypoxemia after standard oxygen therapy. It should be undertaken in an airborne isolation room and enhanced droplet/airborne PPE should be applied to all the healthcare workers, including N95 masks, hair cover, protective coverall, gown, gloves, face shields and goggles (prepared for anti-fog) and shoe covers. If available, a protective head hood or PAPR should be used. Whenever possible, it should be performed by an experienced anesthesiologist with assistance of another physician. Airway assessment before intervention is regarded as crucial. All airway management tools must be disposable and available including a videolaryngoscope with disposable blades, and devices for needle or scalpel cricothyroidotomy. According to Aminnejad et al.37  and Yang et al.38  the administration of intravenous lidocaine prior to tracheal extubation can reduce coughing without side-effects, and it can be recommended also for intubation aiming to reduce the risk for the physician who is doing the procedure. Several specific recommendations are also afforded for an anticipated difficult airway. The endotracheal tube must be secure and then the patient is put in mechanical ventilation. All devices must be collected in double-sealed bags and proper disinfection implemented during disposal. All equipment and environment surfaces must be cleaned and disinfected.36
Akin to the physicians at high risk, allied health and nursing professionals who care for patients with head and neck diseases continue to be at high risk. Problematic settings include postoperative tracheostomy care and valve changes for laryngectomees. These personnel should adhere to the same PPE recommendations as for other professional groups involved in airway interventions.