Barrier Enclosure for Endotracheal Intubation in a Simulated COVID-19 Scenario: A Crossover Study

Abstract

Introduction Barrier enclosures have been developed to reduce the risk of COVID-19 transmission to healthcare providers during intubation, but little is known about their impact on procedure performance. We sought to determine whether a barrier enclosure delays time to successful intubation by experienced airway operators. Methods We conducted a crossover simulation study at a tertiary academic hospital. Participants watched a four-minute video, practiced one simulated intubation with a barrier enclosure, and then completed one intubation with and one without the barrier enclosure (randomized to determine order). The primary outcome measure was time from placement of the video laryngoscope at the lips to first delivered ventilation. Secondary outcomes were periprocedural complications and participant responses to a post-study survey. Results Proceduralists (n = 50) from emergency medicine and anesthesiology had median intubation times of 23.6 seconds with practice barrier enclosure, 20.5 seconds with barrier enclosure, and 16.7 seconds with no barrier. Intubation with barrier enclosure averaged 4.5 seconds longer (95% confidence interval, 2.7–6.4, p < .001) than without, but was less than the predetermined clinical significance threshold of 10 seconds. Three complications occurred, all during the practice intubation. Barrier enclosure made intubation more challenging according to 48%, but 90% indicated they would consider using it in clinical practice. Conclusion Experienced airway operators performed intubation using a barrier enclosure with minimal increased time to procedure completion in this uncomplicated airway model. Given potential to reduce droplet spread, use of a barrier enclosure may be an acceptable adjunct to endotracheal intubation for those familiar with its use.

Aerosol Box Use in Reducing Health Care Worker Contamination During Airway Procedures (AIRWAY Study)

“…In this study, teams of trained airway practitioners using an aerosol box showed increased time to intubation, but no difference in time to LMA insertion or first-pass success rates (for ETI and LMA insertion) compared with teams without an aerosol box. While prior manikin-based studies report slightly longer time to intubation with aerosol box use, certain study design elements such as a single airway practitioner or a lack of prior aerosol box training may have contributed to delayed intubation times. Data from studies assessing intubation in real patients is mixed.…”

“…Two prospective trials showed no difference in time to intubation or first-pass success rate with aerosol box use, but a survey of practitioners who had used an aerosol box during intubation reported only a 78.9% first-pass success rate . Aerosol box use during intubation requires an increased number of optimization procedures and hand movements, along with hindering visibility for some practitioners . In theory, practicing in pairs should provide sufficient opportunity to overcome these challenges.…”

“…We found minimal amounts of surface contamination postdoffing in both control and intervention groups. Existing literature has described technical challenges associated with box use resulting in prolonged intubation times, 7 , 21 , 23 , 25 , 37 , 44 , 45 , 46 , 47 , 48 raising concerns about patient safety particularly with untrained airway practitioners. 31 This study sought to optimize practitioner performance by training airway teams to use the aerosol box.…”

“…The aerosol box has been implemented by some hospitals worldwide for management of COVID-19 patients who are critically ill. 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 Studies demonstrate that aerosol box use potentially reduces spread of aerosolized particles, 20 , 21 but is often associated with technical challenges. 22 , 23 , 24 , 25 Simulation-based studies describe delayed time to intubation with aerosol box use, but clinical studies largely demonstrate no difference in intubation times. 7 Studies have focused primarily on the task of ETI, with little evidence describing aerosol box use during LMA insertion or BVM ventilation.…”

The FEES box: A novel barrier to contain particles during aerosol-generating procedures

“…In the setting of the COVID-19 pandemic, the need has arisen to emphasize personal protective equipment and barriers for AGPs [ [16] , [17] , [18] , [19] ]. This is particularly salient for SLPs who must perform FEES to assess the swallowing ability of COVID patients.…”