l Connue nasal oxygen using O flow at 5 L/min 2 l Maximum two more aempts preferably with a videolaryngoscope (repeat aempts only if SpO ≥95%) 2 l Gentle mask venlaon between aempts (if SpO2 95%) with two-person technique and opmal mask fit * l Opmise posion, use external laryngeal manipulaon, release cricoid pressure, use bougie / stylet if required l Consider changing device/ technique/ operator between aempts l Maintain depth of anaesthesia and opmal neuromuscular blockade Confirm tracheal intubaon using capnography Consider one of the following opons : 1. Preferably wake up the paent 2. Connue anaesthesia using the SAD only if considered safe for the paent, keeping in mind the risk of aerosolisaon 3. Tracheostomy and tracheal intubaon through SAD are not preferred Wake up the paent l Connue nasal oxygen using O flow at 5 L/min 2 l Use second generaon SAD l Maximum two aempts (only if SpO ≥ 95%) 2 l Gentle mask venlaon between aempts (if SpO2 95%) with two-hand two-person technique and opmal mask fit* l Consider changing size or type of SAD l Maintain depth of anaesthesia and opmal neuromuscular blockade l Connue nasal oxygen using O flow at 5 L/min 2 l Ensure neuromuscular blockade l Final aempt at gentle mask venlaon* using opmal technique l Connue nasal oxygen using O flow at 5 L/min and efforts 2 at rescue mask venlaon l Perform surgical cricothyroidotomy with opmal neuromuscular blockade Management of Unancipated Difficult Tracheal Intubaon in Adults during the COVID-19 Pandemic STEP 1: Laryngoscopy and tracheal intubaon Unable to intubate during first aempt at direct / videolaryngoscopy STEP 4 : Emergency cricothyroidotomy STEP 3: Rescue face mask venlaon STEP 2: Insert SAD to maintain oxygenaon Failed Intubaon Failed Venlaon through SAD Complete Venlaon Failure CALL FOR ADDITIONAL HELP If necessary, resume Gentle Mask Venlaon* (with opmal mask fit) with 100% O 2 This flow chart should be used in conjuncon with the text SAD = Supragloc airway device O= Oxygen 2 PPE =Personal Protecve Equipment SpO = Oxygen saturaon 2 Bold underlined text represents modificaons in AIDAA algorithm. *A viral filter should be present between the mask and the breathing circuit and the paent’s face should be covered with a transparent plasc sheet or a customised intubaon box during mask venlaon. Succeed Succeed C A L L F O R H E L P Post- procedure plan Succeed 1. Ensure proper disposal of single use items and disinfection of reusable items as per the institutional policy 2. Supervised doffing of PPE with proper disposal, followed by hand hygiene 3. Further airway management plan 4. Treat airway oedema if suspected 5. Monitor for complications 6. Counselling and documentation 7. Debriefing ApekshPatwa,AmitShah,RakeshGarg,JigeeshuVasishthaDivatia,PankajKundra,JesonRajanDoctor,SumalathaRadhakrishnaShetty,SyedMoied Ahmed,SabyasachiDas,SheilaNainanMyatra,AllIndiadifficultairwayassociation(AIDAA)consensusguidelinesforairwaymanagement intheoperatingroomduringtheCOVID-19pandemic.IndianJAnaesth2020;64:S107-15