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Letters to Editor
Barrier enclosure for airway
management in COVID‑19
pandemic
Sir,
The novel coronavirus pandemic is taking a
tremendous toll on the lives of health care
workers. The asymptomatic clinical presentation
of coronavirus disease 2019 (COVID‑19)[1] poses
high risk during intubation and extubation when
enormous droplet scatter is anticipated. Centres for
Disease Control and Prevention recommends surface
disinfection rather than fumigation or wide‑area
spraying of contaminated surfaces.[2] In view of the
exponential rise in the number of COVID‑19 cases,
there are chances of improper disinfection of
operating rooms (OR)/intensive care units (ICU).
So we need additional barriers to reduce surface
contamination and allow safe reuse of personal
protective equipment (PPE) under circumstances of
diminishing PPE supply.
The concept of aerosol box was first formulated
by Dr. Lai Hsien‑yung, an anaesthesiologist from
Taiwan.[3] The efficacy of the box in reducing droplet
scatter has been studied in a Mannequin with the
simulation of cough.[4] The name aerosol box is however
a misnomer, as there cannot be absolute containment
of aerosols generated during airway interventions.
The original design is a 50 × 50 × 40 cm box with
two armholes of 10 cm diameter. The side panels are
rectangular and there is no front panel.[5]
The box we made has a front panel, upper surface,
intubator surface with two armholes (12 cm
diameter), and two side panels with C‑shaped
curves [Figure 1]. The box is made of high‑quality
4 mm transparent acrylic sheet with a gross weight
of 3900 g. A single sheet was used to make the front
panel, upper surface, and intubator surface, creating
a smooth curve at the bends to avoid aberrations
and blind spots. [Figure 2] As the average width of
OR table is 50 cm, the reduction in base‑width from
50 cm to 48 cm offered more stability and avoided
fall with slight movement when using in OR.
C‑shaped curves helped to make laryngoscopy easy
in obese individuals, as they could rest their arms
comfortably on arm boards allowing the breasts
Indian Journal of Anaesthesia | Volume 64 | Supplement 2 | May 2020
Page no. 75
Figure 1: Dimensions of the aerosol box
to fall laterally. The anaesthesia circuit was taken
inside from below the front panel, whereas the side
curves gave sufficient space for the assistant to apply
cricoid pressure, pass the endotracheal tube, remove
stylet, etc. In obese patients, to align the external
auditory meatus in the same horizontal plane as
the sternal notch, we elevated the backplate of OR
table by 25 degrees[6] and horizontalised the head
rest. The box could be conveniently placed under
such circumstances. The same might not be possible
in morbidly obese patients. Upon our experience
in more than fifty patients, including critically
ill, we found laryngoscopy convenient with both
video laryngoscope and Macintosh laryngoscope.
Whenever airway difficulty was encountered, the box
was lifted off the patient by the assistant and placed
bedside. As there is an inevitable restriction in the
physician’s range of motion during the procedure,
we suggest simulation‑based training for clinicians
before using it in OR/ICU so as to increase operator
familiarity. The box has minimal corners and bends
and can be easily disinfected by wiping with 0.5%
hypochlorite. There is a possibility of scatter of
droplets over assistant through the gap below the
front panel, and to avoid this we suggest using OR
drapes to cover the open portion. [Figure 2]
Although there cannot be complete protection from
infected aerosols, droplet contamination can be
considerably reduced when airway interventions
are done with the aerosol box.[4] Its benefit during
the intubation of critically ill patients needs more
validation. We feel this enclosure device can protect
health care workers when treating patients suffering
from infections that are transmitted via respiratory
droplets, apart from COVID‑19.
S153
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Letters to Editor

REFERENCES
1. Meng H, Xiong R, He R, Lin W, Hao B, Zhang L, et al. CT
imaging and clinical course of asymptomatic cases with
COVID‑19 pneumonia at admission in Wuhan, China.
J Infect 2020. pii: S0163‑4453(20)30211‑5. doi: 10.1016/j.jinf.
2020.04.004. [Epub ahead of print]
2. Centre for Disease control and Prevention. Interim infection
prevention and control recommendations for patients with
suspected or confirmed coronavirus disease 2019 (COVID‑19)
in healthcare settings. Available from: https://www.cdc.gov/
coronavir us/2019‑ncov/infection‑control/control‑recommend
tions.html. [Last accessed on 2020 Apr].
3. Everington K. Taiwanese doctor invents device to protect
US doctors against coronavirus. Taiwan News. March 23,
2020. (https://www.taiwannew s.com.tw/en/news/3902435).
4. Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R.
Barrier enclosure during endotracheal intubation.N Engl J
Med 2020 Apr 3. doi: 10.1056/NEJMc2007589. [Epub ahead of
Figure 2: Picture shows aerosol box kept on OR table after covering
print]
open portion with a drape. Upper smooth curves can be seen
5. Lai HY, Design A. (2020) Aerosol box‑design. [online] Sites.
google.com. Available from: https://sites.google.com/view/
Authors’   contributions aeroso lbox/design [Last accessed on 2020 May 06].
6. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R,
All authors contributed equally.
Patel A, et al. Difficult airway society 2015 guidelines for
management of unanticipated difficult intubation in adults. Br
Financial support and sponsorship J Anaesth 2015;115:827‑48.
Nil.
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the identical terms.

Karthika Asokan, Bibilash Babu1, Arya Jayadevan2 Access this article online
Department of Anaesthesiology, Regional Cancer Centre,
Quick response code
1
Department of Plastic and Reconstructive Surgery, Cosmetiq
Website:
Clinic, 2Department of Anaesthesiology, Cosmetiq Clinic, Chackai, www.ijaweb.org
Trivandrum, Kerala, India

Address for correspondence:

DOI:
Dr. Karthika Asokan, 10.4103/ija.IJA_413_20
Department of Anaesthesiology, Regional Cancer Centre, Trivandrum,
Kerala ‑ 695 011 India.
E‑mail: drkarthikaasokan@gmail.com

Submitted: 20‑Apr‑2020
Revised: 25‑Apr‑2020
Accepted: 06‑May‑2020
Published: 23-May-2020
How to cite this article: Asokan K, Babu B, Jayadevan A. Barrier
enclosure for airway management in COVID‑19 pandemic. Indian J
Anaesth 2020;64:S153-4.
© 2020 Indian Journal of Anaesthesia | Published by Wolters Kluwer - Medknow

Aerosol containment device Infection is transmitted mainly through droplets and

aerosols that remain suspended in the air for a longer
for use on suspected period.[1] The main risk is at the time of intubation
or extubation which are high aerosol generating
COVID‑19 patients activities (AGPs). We have developed a novel device
that limits the escape of aerosol and thus minimizes
the risk of transmission of infection.
Sir,
The device consists of two cross bars held in place by
The current pandemic of COVID‑19 has opened up two rods that pass through small metal tubes fixed at
new challenges for the healthcare workers (HCWs) the base of the cross bars [Figure 1]. The cross bars
who may get infected in the course of care activities. can be moved up and down on the rods that connects

S154 Indian Journal of Anaesthesia | Volume 64 | Supplement 2 | May 2020

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