To the Editor We read with interest the article by Thiruvenkatarajan et al1 on airway management in the operating room and interventional suites in coronavirus disease 2019 (COVID-19) patients. We applaud the clarity of their review, prioritizing safety for health care workers (HCW) who perform aerosol-generating procedures. Because the COVID-19 pandemic is ongoing with no end in sight, it is expected that many people, including HCW, may experience pandemic fatigue, and adhering to guidelines for safe airway management may become increasingly challenging. Recently, a small observational study demonstrated that intubation and extubation did not generate aerosol in healthy individuals and concluded that “elective tracheal intubation should not be designated as an aerosol-generating procedure.”2 However, we share the sentiment with Thiruvenkatarajan et al1 that HCW performing airway maneuvers should be considered at high risk of contracting respiratory infections until proven otherwise by well-designed, robust randomized-control trials, especially amid the COVID-19 pandemic. In the meantime, the local guidelines should reflect the high-risk nature for infection of such procedures. Although most tracheal intubations performed in the operating rooms are controlled, the nature of intubation is unpredictable with the unanticipated difficulty being possible, not to mention the possibility of a patient coughing or bucking during airway maneuvers with suboptimal effect of a nondepolarizing muscle relaxant or the subsiding effect of depolarizing muscle relaxant in the presence of unplanned prolonged airway maneuvers. Furthermore, we agree that video laryngoscopy should be used in the first instance to protect HCW, even though this translates to trainees getting less exposure to direct laryngoscopy. As mentioned by Thiruvenkatarajan et al,1 extubation is less controlled than intubation with regard to aerosol generation and droplet dispersion. It has been shown that around 40% of patients cough at the time of extubation, but it can be as high as 70% after awake extubation.3 Deep extubation performed with oropharyngeal airway and jaw thrust in selected patients, or facemask covering the patient’s airway immediately following awake extubation, may reduce aerosol or droplet spread. It has been demonstrated that individuals with influenza produce a significantly greater volume of aerosol and higher number of particles per cough when ill compared with afterward. There was also a higher volume of particles that could reach the alveolar region of the lungs if inhaled by another person.4 Respiratory infection, including COVID-19 transmission, depends on the viral load of the patients at the time of airway maneuver, with multiple factors affecting aerosol generation, including cough velocity, mucous density, surface tension, surface properties that line the airway, and viscosity.5 One of the lessons from the COVID-19 pandemic is the recognition that intubation and facemask ventilation are high-risk events for transmission for viral respiratory pathogens, even though the risk of transmission may not entirely be due to aerosol generation.6 With the complexity and multifactorial process of pathogen transmission, one should err on the side of caution and utilize personal protective equipment (PPE) appropriate to cover droplet, contact, and aerosol precautions when intubating or extubating proven or suspected COVID-19 patients, until there is clinical evidence that intubation and extubation are not high-risk events for transmission. The standards for protecting HCW should not be set at the bare minimum. If the idea is to be resource conscious, there needs to be an effort by health care institutions to adapt reusable and sustainable solutions. Unlike prion disease, coronavirus can be effectively eliminated by normal cleaning practices. Reusable equipment can be used to preserve scarce resources while protecting the environment. We would like to reinforce the requirement that those performing airway maneuvers take proper precautions and don appropriate PPE for personal safety and disease containment and to remember that “an infected lung is potentially an infectious lung.” This is particularly true when pandemic fatigue may lead to complacency while preparing for a second surge in COVID-19 cases worldwide. Vivian H. Y. Ip, MBChB, FRCADepartment of Anesthesia and Pain MedicineUniversity of AlbertaEdmonton, Alberta, Canada[email protected] Rakesh V. Sondekoppam, MBBS, MDDepartment of AnesthesiaUniversity of Iowa HospitalIowa City, Iowa