Managing the Difficult Airway in Critically Ill COVID-19 Patients: A Case Series and Lessons Learned

Background: The COVID-19 pandemic has placed anesthesiologists at the forefront of managing critically ill patients requiring emergency tracheal intubation. The unique challenges posed by difficult airways, combined with the risks of viral transmission, have necessitated significant modifications in airway management protocols. Objective: This case series of three emergency intubations highlights the practices, experiences, and challenges encountered by anesthesiologists during emergency tracheal intubation of critically ill COVID-19 patients with difficult airways in a tertiary referral hospital in the Philippines. Methods: We present three cases of emergency intubations in COVID-19 patients with difficult airways, defined using modified Mallampati classification ≥3, limited mouth opening (<3 cm), reduced neck extension (<35？), or anatomical distortion. Success rates and patient outcomes were tracked through hospital discharge. Results: All three patients (79-year-old female with comorbidities, 28-year-old male with morbid obesity, 42-year-old female with neck mass) presented unique airway challenges. Success rates were 33% on the first attempt, and 67% on the second attempt, with one case requiring surgical airway. All patients survived to ICU admission with successful airway management. Hospital policies were subsequently updated to mandate early anesthesiology consultation for anticipated difficult airways. Conclusions: Emergency tracheal intubation in COVID-19 patients with difficult airways presents significant challenges. Videolaryngoscopy, multidisciplinary teamwork, hemodynamic optimization, and early intubation referral improve outcomes while protecting healthcare workers.