Aerosol boxes and barrier enclosures for airway management in COVID-19 patients: a scoping review and narrative synthesis

Abstract

Exposure of healthcare providers to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a significant safety concern during the coronavirus disease 2019 (COVID-19) pandemic, requiring contact/droplet/airborne precautions. Because of global shortages, limited availability of personal protective equipment (PPE) has motivated the development of barrier-enclosure systems, such as aerosol boxes, plastic drapes, and similar protective systems. We examined the available evidence and scientific publications about barrier-enclosure systems for airway management in suspected/ confirmed COVID-19 patients. MEDLINE/Embase/Google Scholar databases (from December 1, 2019 to May 27, 2020) were searched for all articles on barrier enclosures for airway management in COVID-19, including references and websites. All sources were reviewed by a panel of experts using a Delphi method with a modified nominal group technique. Fiftytwo articles were reviewed for their results and level of evidence regarding barrier device feasibility, advantages, protection against droplets and aerosols, effectiveness, safety, ergonomics, and cleaning/disposal. The majority of analysed papers were expert opinions, small case series, technical descriptions, small-sample simulation studies, and pre-print proofs. The use of barrier-enclosure devices adds to the complexity of airway procedures with potential adverse consequences, especially during airway emergencies. Concerns include limitations on the ability to perform airway interventions and the aid that can be delivered by an assistant, patient injuries, compromise of PPE integrity, lack of evidence for added protection of healthcare providers (including secondary aerosolisation upon barrier removal), and lack of cleaning standards. Enclosure barriers for airway management are no substitute for adequate PPE, and their use should be avoided until adequate validation studies can be reported.

Macintosh laryngoscope, i-view™, and C-MAC® video laryngoscopes for tracheal intubation with an aerosol box: A randomized, crossover, manikin study

“…When evaluating a novel device, such as the aerosol box, the learning effect should be considered. The use of the aerosol box is highly controversial [12][13][14][15][16][17][18][19][20][21][22]. We believe that the current simulation study results would be referred for the safe use of aerosol boxes in clinical practice.…”

“…It is necessary to examine the safety and e cacy of aerosol boxes in clinical practice. Evidence for the use of aerosol boxes in real patients is lacking and needs to be studied in the near future [22]. Second, differences in the participants' familiarity with the three laryngoscopes might have affected the results.…”

A simple method to prevent aerosol dispersion during Cardiopulmonary Resuscitation using supraglottic airway devices

“…were proposed recently as a barrier method to prevent aerosol dispersion during CPR. 6 However, it has shown controversial results and there is only evidence that personal protective equipment protects healthcare practitioners. 6 We describe the use of an endoscopic mask (VBM Sulz, Germany) with the support of harnesses to assemble over the SAD as an aerosol anti-leak method.…”

“…6 However, it has shown controversial results and there is only evidence that personal protective equipment protects healthcare practitioners. 6 We describe the use of an endoscopic mask (VBM Sulz, Germany) with the support of harnesses to assemble over the SAD as an aerosol anti-leak method. The mask is inserted over the proximal end of the SAD through its flexible membrane, which guarantees an adequate seal that prevents airway leak and aerosolization.…”

Pediatric barrier enclosure for nasopharyngeal suctioning during Covid-19 pandemic: A simulation based-study

“…In addition to the use of Personal Protective Equipment (PPE), plastic barrier enclosure was designed to reduce the risk of transmission during intubation of Covid-19 patients, mainly in the operating room and intensive care unit [ 3 ]. It is a large plexiglass box installed above the head and torso of a patient lying supine during advanced airway procedure.…”