Comparison of the Effectiveness of Different Barrier Enclosure Techniques in Protection of Healthcare Workers During Tracheal Intubation and Extubation

Ibrahim, Mohamed; Khan, Ejaz; Babazade, Rovnat; Simón, M.; Vadhera, Rakesh

doi:10.1213/xaa.0000000000001252

Cited by 13 publications

(13 citation statements)

References 6 publications

(6 reference statements)

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“…Box designs were often similar to the original design in Canelli et al [ 7 ], which is a transparent 4-sided structure with two open faces: an inferior face bound by the stretcher and a caudal face pointed towards the foot of the bed. Common modifications included change in the number or size of ports (i.e., for operators and/or tools) [ [8] , [9] , [10] , [11] , [12] ], increased device size for improved operator ergonomics and/or patient body habitus [ [13] , [14] , [15] ], built-in gloves and/or port coverings [ 11 , 12 , 16 , 17 ], addition of a plastic drape or covering on the caudal face [ [18] , [19] , [20] ], a sloped top panel for improved visibility [ 15 , 18 , 21 ] and the use of a negative suction system [ [22] , [23] , [24] ].…”

Section: Resultsmentioning

confidence: 99%

“…Five articles compared the box and plastic sheet systems [ 13 , 20 , 21 , 24 , 87 ]. In Brown et al [ 87 ], Ibrahim et al [ 20 ]., and Gore et al [ 21 ], particles escaped through the open caudal end of box systems with increased contamination of the operator and/or environment relative to the plastic systems during airway management. Laosuwan et al also assessed droplet contamination on a standardized grid in an extubation simulation and similarly reported increased contamination with box systems relative to plastic sheet systems [ 13 ].…”

Section: Resultsmentioning

confidence: 99%

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Barrier enclosure use during aerosol-generating medical procedures: A scoping review

Price

Ben-Yakov

Choi

et al. 2021

The American Journal of Emergency Medicine

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Introduction Barrier enclosure devices were introduced to protect against infectious disease transmission during aerosol generating medical procedures (AGMP). Recent discussion in the medical community has led to new designs and adoption despite limited evidence. A scoping review was conducted to characterize devices being used and their performance. Methods We conducted a scoping review of formal databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, CENTRAL, Scopus), grey literature, and hand-searched relevant journals. Forward and reverse citation searching was completed on included articles. Article/full-text screening and data extraction was performed by two independent reviewers. Studies were categorized by publication type, device category, intended medical use, and outcomes (efficacy – ability to contain particles; efficiency – time to complete AGMP; and usability – user experience). Results Searches identified 6489 studies and 123 met criteria for inclusion (k = 0.81 title/abstract, k = 0.77 full-text). Most articles were published in 2020 (98%, n = 120) as letters/commentaries (58%, n = 71). Box systems represented 42% ( n = 52) of systems described, while plastic sheet systems accounted for 54% ( n = 66). The majority were used for airway management (67%, n = 83). Only half of articles described outcome measures (54%, n = 67); 82% ( n = 55) reporting efficacy, 39% ( n = 26) on usability, and 15% ( n = 10) on efficiency. Efficacy of devices in containing aerosols was limited and frequently dependent on use of suction devices. Conclusions While use of various barrier enclosure devices has become widespread during this pandemic, objective data of efficacy, efficiency, and usability is limited. Further controlled studies are required before adoption into routine clinical practice.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Barrier enclosure use during aerosol-generating medical procedures: A scoping review

Price

Ben-Yakov

Choi

et al. 2021

The American Journal of Emergency Medicine

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“…On the contrary, box devices which open caudally (towards the patient’s feet) at best segregate the user from potentially infectious aerosols but present more opportunities for transmission to other providers in the room. In keeping with the hierarchy of effectiveness for control measures, this has been demonstrated in comparative studies ( Brown et al , 2020 ; Gore et al , 2020 ; Ibrahim et al , 2020 ) showing increased contamination of providers as a result of particles escaping through the open caudal face of box systems relative to enclosed plastic sheet systems.…”

Section: Discussionmentioning

confidence: 77%

Intubator Performance and Contamination with the Use of Barrier Enclosure Devices: Results from a Simulated COVID-19 Resuscitation

Ben-Yakov

Price

Dharamsi

et al. 2021

Annals of Work Exposures and Health

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Introduction Medical institutions are using barrier enclosure devices during intubation procedures and other aerosol-generating medical procedures without evidence of their effectiveness or usability, potentially compromising patient care, and provider safety. Our objective was to determine the degree of protection offered by these devices and explore other usability factors for two popular barrier systems. Methods A simulated trial comparing an intubation box, a frame and plastic tarp system, and unprotected intubation was performed in an academic emergency department. Ten emergency physicians were recruited to participate. Our primary outcome was the degree of contamination from secretions measured by average surface area exposed to phosphorescent material. Secondary outcomes included: laryngoscopy time and time to barrier application, unsuccessful intubation attempts, and usability ratings for each system. Descriptive statistics were reported for all variables of interest and a linear mixed model was used to analyze contamination and laryngoscopy time. Usability was captured through electronic questionnaires using a five-point Likert scale. Results Contamination was more prevalent with the box, compared to the frame and tarp, and no device, however, this did not achieve statistical significance (13.2% versus 8.1% versus 12.2%, P = 0.17). A barrier system delayed intubation when compared to using no system (no system = 24.4 s [95% CI 17.3–27.5], frame = 54.4 s [95% CI 13.8–95.0], box = 33.8 s [95% CI 21.4–46.1], P = 0.02). In assessing usability, 30% of users preferred the use of a box barrier, 40% of users preferred the frame, and 30% would not use either in future intubation. Conclusions Compared to no barrier protection, an intubation box enclosure offers limited additional protection. A frame and tarp system reduces exposure at the expense of visibility and operator comfort. Finally, barrier systems do not appear to have a clinically significant impact on airway management.

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“… 8 Efficacy data available thus far have been conflicting; certain barrier enclosure designs have actually been shown to promote an increase in aerosol exposure to the laryngoscopist through the arm holes. 25 – 27 Proper safety studies, conducted with a discrete group of airway providers experienced in the use of barrier enclosure in altered contexts, are also lacking. 6 The lack of firm efficacy and safety data led the U.S. Food and Drug Administration to revoke its authorization of the emergency use of COVID-19 barrier enclosures on 22 August 2020.…”

Section: Discussionmentioning

confidence: 99%

The impact of a barrier enclosure on time to tracheal intubation: a randomized controlled trial

Jen

Gusti

Badh

et al. 2021

Can J Anesth/J Can Anesth

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Purpose Novel devices such as the barrier enclosure were developed in hopes of improving provider safety by limiting SARS-CoV-2 transmission during tracheal intubation. Nevertheless, concerns arose regarding a lack of rigorous efficacy and safety data for these devices. We conducted a randomized controlled trial to evaluate the impact of the barrier enclosure on time to tracheal intubation. Method After Research Ethics Board approval, elective surgical patients with normal airway predictors were randomly allocated 1:1 to tracheal intubation with or without a barrier enclosure. The primary outcome was time to tracheal intubation. Secondary outcomes included first-pass success rate, total time of airway manipulation, anesthesiologists’ perception of intubation difficulty, likelihood of use in SARS-CoV-2-positive patients, and patients’ perception of comfort and acceptability. Results There were 48 participants in the barrier enclosure group and 46 participants in the control group. The mean (standard deviation [SD]) time to tracheal intubation was 62 (29) sec with barrier closure and 53 (27) sec without barrier enclosure (mean difference, 9 sec; 95% confidence interval, − 3 to 20; P = 0.14). Anesthesiologists rated the difficulty of intubation higher with barrier enclosure (mean [SD] visual analogue scale score, 27 [26] mm vs 9 [17] mm; P < 0.001). There were no significant differences in other secondary outcomes. Conclusion In healthy surgical patients with normal airway predictors, the use of a barrier enclosure during tracheal intubation did not significantly prolong time to intubation or decrease first-pass intubation success. Nevertheless, there was an increase in difficulty of intubation perceived by the anesthesiologists with use of a barrier enclosure. Trial registration www.clinicaltrials.gov (NCT04366141); registered 28 April 2020. Supplementary Information The online version contains supplementary material available at 10.1007/s12630-021-02024-z.

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Comparison of the Effectiveness of Different Barrier Enclosure Techniques in Protection of Healthcare Workers During Tracheal Intubation and Extubation

Cited by 13 publications

References 6 publications

Barrier enclosure use during aerosol-generating medical procedures: A scoping review

Barrier enclosure use during aerosol-generating medical procedures: A scoping review

Intubator Performance and Contamination with the Use of Barrier Enclosure Devices: Results from a Simulated COVID-19 Resuscitation

The impact of a barrier enclosure on time to tracheal intubation: a randomized controlled trial

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