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 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 154-156

Airway suctioning during the COVID-19 era: A simple method to minimise surface contamination

Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission27-Aug-2020
Date of Acceptance02-Oct-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Dr. Sunaakshi Puri
Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_35_20

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How to cite this article:
Gupta A, Puri S. Airway suctioning during the COVID-19 era: A simple method to minimise surface contamination. Airway 2020;3:154-6

How to cite this URL:
Gupta A, Puri S. Airway suctioning during the COVID-19 era: A simple method to minimise surface contamination. Airway [serial online] 2020 [cited 2023 Jun 7];3:154-6. Available from: https://www.arwy.org/text.asp?2020/3/3/154/304845

The coronavirus disease 2019 (COVID-19) pandemic has had far-reaching effects on the healthcare system worldwide and has contributed significantly to morbidity and mortality. Healthcare workers face a much higher risk of acquiring the infection compared to the general population. Cross-sectional studies from various facilities suggest infection rate amongst healthcare workers ranging from 10% to 20%.[1] Transmission of COVID-19 infection occurs through airborne droplets from nose and oral cavity containing infective organisms in saliva and sputum. Respiratory droplets are >5–10 μm in diameter, whereas droplets <5 μm in diameter are referred to as droplet nuclei.[2] In addition to airborne transmission of infection, direct contact with oral or nasal secretions as well as indirect contact with contaminated instruments or environmental surfaces may also lead to disease transmission. Endotracheal intubation and airway suctioning are categorised as aerosol-generating procedures (AGPs) with a high potential of causing airborne transmission of infection. Because anaesthesiologists routinely perform high AGPs in the operating room as well as non-operating room locations, they are at a grave risk of being infected during the COVID era.[3]

At the beginning of the COVID outbreak, elective surgeries were temporarily suspended in most hospitals to avoid overwhelming the healthcare system already struggling with the rising COVID cases and also to protect the patients. This measure was adopted to curtail disease transmission and conserve resources such as personal protective equipment, hospital beds and workforce to address the COVID-19 outbreak. In addition, our surgical colleagues were inducted into the COVID-19 hospital response team to cater to the demands of the healthcare system.[4] However, elective surgeries could not be postponed indefinitely for the risk of increasing backlog of cases, and complications and mortality among patients kept waiting. In the worst scenario, elective surgeries could have even turned into emergency procedures. Hence, most institutions gradually and systematically resumed urgent and semi-elective surgeries with preoperative COVID testing and adequate personal protective measures. In a tertiary care hospital such as ours, all patients scheduled for surgery are currently being tested for COVID-19 infection within 48 h before surgery. However, the low sensitivity of laboratory testing warrants strict adherence to precautionary measures even when caring for patients who have tested negative.[5]

Compliance with standard checklists and guidelines during airway interventions may enhance the safety of healthcare providers in operation theatre.[6] At the conclusion of surgery, thorough suctioning of the oropharynx prior to extubation is a crucial step in ensuring smooth emergence without any untoward complication. Face masks, face shields and the intubation box protect the operating room staff from infection by aerosols generated during airway suctioning. In addition to the risk of airborne infection from aerosols generated during suctioning, handling of the suction catheter soiled with airway secretions can also serve as a source of surface contamination. Keeping this in mind, we devised a safe method to perform airway suctioning for patients in the perioperative setting prior to extubation. The sequence of steps that we follow while performing suctioning using this technique is illustrated in [Figure 1]. Adopting this technique provides various advantages. It avoids direct handling of the suction catheter by the anaesthesiologist, both during and after performing suction, thus minimising the spread of infection both to and from the patient. It also helps to decrease the contamination of inanimate surfaces by the soiled catheter. We have been successfully using this technique routinely in our operating rooms for the past 6 months, irrespective of the COVID report status of the patient. We have practiced this technique in 228 patients aged 6 months to 12 years along with other protective measures, and none of the doctors and technical staff working in the operation theatre premises has contracted COVID infection.
Figure 1: Proposed steps of suctioning to minimise surface contamination: (a) Suction catheter within an intact plastic cover (b) Cover cut open at the patient end to expose the length of tip just adequate to be inserted into the airway (c) Suctioning is performed while holding the catheter inside its cover (d) Once thorough suctioning is complete, the catheter tip is withdrawn to put back it within its cover

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By using this technique, we may be successful in preventing the spread of not only coronavirus, but also other infectious respiratory tract illnesses in the future. A cost-effective alternative to closed suction apparatus has been described by Vargas and Servillo using ultrasound probe cover.[7] Similarly, covering the patient with plastic drapes or placing a Hudson mask over the face following intubation is another method described to contain the aerosols generated and prevent the spread of infection.[8] The development of safe, cost-effective and sustainable medical practices in the current scenario is of utmost importance to safeguard healthcare workers as well as vulnerable patients in their care, especially in resource-poor settings in developing countries.


We acknowledge the contribution of Poonam Chaudhary, Diploma Operation Theatre Technology, working as Senior Operation Theatre Technician in Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India for her technical expertise and assistance in devising the procedure and in acquisition of images.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Nguyen LH, Drew DA, Joshi AD, Guo CG, Ma W, Mehta RS, et al. Risk of COVID-19 among frontline healthcare workers and the general community: A prospective cohort study. Preprint. medRxiv. 2020;2020.04.29.20084111. Published 2020 May 25. doi:10.1101/2020.04.29.20084111.  Back to cited text no. 1
World Health Organization. Infection Prevention and Control of Epidemic-and Pandemic-Prone Acute Respiratory Infections in Health Care. Geneva: World Health Organization; 2014. Available from: https://apps.who.int/iris/bitstream/handle/10665/112656/9789241507134_eng.pdf;jsessionid=41AA684FB64571CE8D8A 453C4F2B2096?sequence=1). [Accessed on 2020 Oct 01].  Back to cited text no. 2
Chen X, Liu Y, Gong Y, Guo X, Zuo M, Li J, et al. Perioperative management of patients infected with the novel coronavirus: Recommendation from the Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists. Anesthesiology 2020;132:1307-16.  Back to cited text no. 3
Diaz A, Sarac BA, Schoenbrunner AR, Janis JE, Pawlik TM. Elective surgery in the time of COVID-19. Am J Surg 2020;219:900-2.  Back to cited text no. 4
Arevalo-Rodriguez I, Buitrago-Garcia D, Simancas-Racines D, Zambrano Achig P, del Campo R, Ciapponi A, et al. False-negative results of initial RT-PCR assays for COVID-19: A systematic review. medRxiv 2020. [Doi: 10.1101/2020.04.16.20066787].  Back to cited text no. 5
Patwa A, Shah A, Garg R, Divatia JV, Kundra P, Doctor JR, et al. All India difficult airway association (AIDAA) consensus guidelines for airway management in the operating room during the COVID-19 pandemic. Indian J Anaesth 2020;64:S107-S115.  Back to cited text no. 6
Vargas M, Servillo G. Closed-suction system for intubated COVID-19 patients with the use of an ultrasound probe cover. Anesthesiology 2020;133:687-9.  Back to cited text no. 7
Au Yong PS, Chen X. Reducing droplet spread during airway manipulation: Lessons from the COVID-19 pandemic in Singapore. Br J Anaesth 2020;125:e176-8.  Back to cited text no. 8


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