IJC_702_20R6_C

Commentary

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AQ2
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Barrier devices for aerosol‑generating procedure during 1
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COVID‑19 pandemic 3
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5 Vinod Kumar, Nishkarsh Gupta 5
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Department of Onco‑Anaesthesia and Palliative Medicine, Dr BR Ambedkar IRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi,
7 India 7
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9 Correspondence to: Vinod Kumar, E‑mail: vkchanpadia@gmail.com 9
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11 Coronavirus disease 2019 (COVID‑19) epidemic has re‑intubation. Also, the anesthesiologists may get 11
12 resulted in patients with varying severity of respiratory self‑contaminated and improper disposal of the plastic 12
13 problems. Anesthetists are frequently involved in cover sheet can lead to cross‑contamination of the 13
14 patient’s airway management, resuscitation, health care workers. 14
15 and critical care. The risk posed to health care 15
Barrier Devices with their Pros and Cons AQ3
16 workers (HCW) during aerosol‑generating procedures 16
17 (AGP) such as intubation and extubation is significant, The design of barrier devices for intubation and AGP 17
18 especially when compounded by the limited availability is continuously evolving. Initially, carton boxes with 18
19 of personal protective equipment (PPE).[1] Improper transparent drapes followed by acrylic boxes were 19
20 precautions during AGP may increase the risk of used for AGP.[5] Matava et al. have used clear plastic 20
21 infections to HCWs. The most important thing to drape in three panels with the first layer placed over 21
22 prevent infections is hand hygiene, proper use of the linen and operating table and second layer placed 22
23 PPE, and proper doffing off after the procedure. 23
over the neck and chest and third layer overhead
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Though the risk of infection spread during intubation covering till mid‑sternum. [6] Plastic drape sheet is
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is well documented, extubation is as risky and disposable, inexpensive, and has less restriction to
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coughing during extubation may additionally lead to hand movements.
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28 aerosol generation and pose risks to HCWs. The The Acrylic barrier box having two circular arm 28
29 ideal method to mitigate such risk is the presence ports for airway handling protects providers from 29
30 of negative pressure rooms for such AGPs. Deep aerosolized particulate. It helps in reducing droplet 30
31 extubation is suggested in guidelines to reduce cough, dispersal and a direct splash of secretions on the 31
32 and several drugs like lignocaine, dexmedetomidine, face of laryngoscopists. However, the aerosol boxes 32
33 remifentanil, and fentanyl have also been tried to have their limitations like inappropriate cleaning 33
34 reduce the cough. [2,3] However, these measures may lead to cross‑contamination, it’s difficult to 34
35 may reduce the incidence of cough but may not use in an agitated and uncooperative patient, 35
36 eliminate it. ergonomically cumbersome to operate in difficult 36
37 airway scenario, possible contamination of assistants 37
38 The need for barrier device arises to reduce the 38
during equipment handover, and urgent removal
39 exposure of HCW to aerosols during the AGPs. An 39
of the box during airway crisis. [7] We use a basic
40 ideal barrier device should protect the user form 40
version of the barrier device in our setup that
41 aerosols by physical barrier, allow assessment of 41
is cleaned in between each use with 70% ethyl
42 oxygenation during AGP, have a system to inactivate 42
alcohol or freshly prepared 1% sodium hypochlorite
43 viral load that may be generated during the AGPs, 43
solution applied for at least 10 min and then cleaned
44 and is ergonomically easy to operate during airway 44
with a damp cloth [Figures 1 and 2] Intubation
45 manipulation. 45
Aerosol Containment System (IACS) is made up
46 In this issue, Bakshi et al. have created a barrier of rigid polycarbonate having integrated sleeves 46
47 using green transparent plastic drape which was 47
and plastic drapes which offer superior protection
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spread over two surgical screen holders and these to laryngoscopist and assistant from aerosols. It
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were attached to the head end of the operating contains two circular arm ports with flexible extension
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table.[4] However, there are some concerns with the sleeves for airway handling.[8] A thin, plastic drape is
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use of this device like it may hamper the visualization attached to the superior and lateral edges of the box
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of the airway especially if the patient requires for additional protection from aerosols.[9] Balloon for

© 2020 Indian Journal of Cancer | Published by Wolters Kluwer ‑ Medknow 1

 Indian Journal of Cancer

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15 Figure 1: Acrylic box for aerosol containment during intubation. A‑Port 15
16 for laryngoscopist’s hand. B‑Port for fiberoptic Figure 2: Aerosol box showing ports with hand sleeve for 16
17 laryngoscopist and assistant. (Courtesy Dr. J Balavenkat) 17
18 Aerosol Protection (BAP) is a big balloon with built‑in 18
19 glove covers. It`s an airtight protective device in which devices with inbuilt suction ensuring requisite air 19
20 the patient can move his head and laryngoscopist can circulation that mitigate aerosolization should be 20
21 do airway manipulation at will. Since it is a closed preferred over the makeshift arrangements. We need 21
22 device; there is a possibility of CO2 retention or to train our HCW in proper usage and cleaning of 22
23 hypoxia if used for a prolonged duration. Operators these barrier devices during high‑risk procedures to 23
24 should tear off the balloon if the patient requires ensure their safety. 24
25 re‑intubation or other respiratory support. [10] The 25
References
26 use of adjuncts and fiberoptic bronchoscope may 26
27 be difficult in most of the available intubation 1. Tran K, Cimon K, Severn M, Pessoa‑Silva CL, Conly J. Aerosol 27
28 generating procedures and risk of transmission of acute respiratory 28
boxes due to the limitation of the space available infections to healthcare workers: A systematic review. PLoS One
29 for manipulation of this equipment. Some acrylic 29
2012;7:e35797.
30 2. Cook TM, El‑Boghdadly K, McGuire B, McNarry AF, Patel A, 30
boxes have a special port for bougie and fiberoptic
31 Higgs A. Consensus guidelines for managing the airway in patients 31
bronchoscope for managing the difficult airway.[11]
32 with COVID‑19: Guidelines from the Difficult Airway Society, the 32
However, there are many reports where the intubation Association of Anaesthetists the Intensive Care Society, the Faculty
33 33
box had to be removed to manage the airway in a of Intensive Care Medicine and the Royal College of Anaesthetists.
34 Anaesthesia 2020;75:785‑99. 34
potentially difficult case. Acrylic box with an in‑situ
35 3. Tung A, Fergusson NA, Ng N, Hu V, Dormuth C, Griesdale DEG. 35
36 portable chamber for negative airflow isolation mimic Medications to reduce emergence coughing after general 36
37 the negative pressure operation theaters and have anaesthesia with tracheal intubation: A systematic review and 37
38 also been developed and used during the COVID‑19 network meta‑analysis. Br J Anaesth 2020;124:480‑95.
pandemic.[12] 4. Bakshi SG, Trivedi B, Patil VP. Use of protective partition during AQ4 38
39 extubation during COVID‑19 pandemic. Indian J Cancer XX;XX:XX. 39
40 People have also tried make‑shift devices like an 5. Lai YY, Chang CM. A carton‑made protective shield for suspicious/ 40
41 confirmed COVID‑19 intubation and extubation during surgery. AQ4 41
orthopaedic hood for AGPs.[13] However, these may Anesth Analg. 2020:10.1213/ANE.0000000000004869. doi:
42 give a false sense of security to the laryngoscopist 10.1213/ANE.0000000000004869.
42
43 and may increase the exposure to aerosols generated 6. Matava CT, Yu J, Denning S. Clear plastic drapes may be effective 43
44 during the procedures. Despite the availability of a at limiting aerosolisation and droplet spray during extubation: 44
45 Implications for COVID‑19. Can J Anaesth 2020;67:902‑4. 45
wide variety of intubation boxes, there is no study 7. Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier
46 that showed the effectiveness of one over the other. 46
enclosure during endotracheal intubation. N Engl J Med
47 2020;382:1957‑8. 47
In the absence of robust literature, a recommendation
48 8. Maniar A, Jagannathan B. The aerosol box. J Anaesthesiol Clin 48
cannot be given for specific use of a particular make
49 Pharmacol 2020;36(Suppl S1):141‑3 49
of the device. 9. Gore RK, Saldana C, Wright DW, Klein AM. Intubation containment
50 50
system for improved protection from aerosolized particles during
51 The use of barrier devices to prevent exposure should airway management. IEEE J Transl Eng Health Med 2020;8:1600103. 51
52 be considered to protect our HCWs during AGPs. 10. Hirose K, Uchida K, Umezu S. Airtight, flexible, disposable barrier for 52
53 However, these barriers are not a substitute for extubation. J Anesth 2020:1‑2. doi: 10.1007/s00540‑020‑02804‑9. 53
54 11. Begley JL, Lavery KE, Nickson CP, Brewster DJ. The aerosol box 54
standard PPE and universal precautions. In absence
for intubation in coronavirus disease 2019 patients: An in‑situ
55 of negative pressure rooms for management of simulation crossover study. Anaesthesia 2020;75:1014‑21.
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56 COVID‑19 during AGPs, several improvised barrier 12. Cubillos J, Querney J, Rankin A, Moore J, Armstrong K. A multipurpose 56

2 Volume 57 | Issue 4 | October-December 2020

 Running title missing??? AQ1

1 portable negative airflow isolation chamber for aerosol‑generating

This is an open access journal, and articles are distributed under the terms of 1
2 procedures during the COVID‑19 pandemic. Br J Anaesth the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, 2
2020;125:e179‑81. which allows others to remix, tweak, and build upon the work non‑commercially,
3 13. Wills TT, Zuelzer WA, Tran BW. Utilization of an orthopedic hood as long as appropriate credit is given and the new creations are licensed under
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4 as personal protective equipment for intubation of coronavirus the identical terms. 4
5 patients: A brief technical report. Geriatr Orthop Surg Rehabil 5
2020;11:2151459320930554. doi: 10.1177/2151459320930554.
6 Access this article online 6
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Website:
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11 DOI: 11
12 10.4103/ijc.IJC_702_20 12
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15 How to cite this article: Kumar V, Gupta N. Barrier devices for aerosol‑generating
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16 procedure during COVID‑19 pandemic. Indian J Cancer 2020;57:XX-XX. 16
17 Submitted: 28‑Jun‑2020 Revised: 01‑Jul‑2020 17
Accepted: 10‑Sep‑2020 Published: ***
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