The aerosol box for intubation in coronavirus disease 2019 patients: an in‐situ simulation crossover study

Abstract

The coronavirus disease 2019 pandemic has led to the manufacturing of novel devices to protect clinicians from the risk of transmission, including the aerosol box for use during tracheal intubation. We evaluated the impact of two aerosol boxes (an early-generation box and a latest-generation box) on intubations in patients with severe coronavirus disease 2019 with an in-situ simulation crossover study. The simulated process complied with the Safe Airway Society coronavirus disease 2019 airway management guidelines. The primary outcome was intubation time; secondary outcomes included first-pass success and breaches to personal protective equipment. All intubations were performed by specialist (consultant) anaesthetists and video recorded. Twelve anaesthetists performed 36 intubations. Intubation time with no aerosol box was significantly shorter than with the early-generation box (median (IQR [range]) 42.9 (32.9-46.9 [30.9-57.6])s vs. 82.1 (45.1-98.3 [30.8-180.0])s p = 0.002) and the latest-generation box (52.4 (43.1-70.3 [35.7-169.2])s, p = 0.008). No intubations without a box took more than 1 min, whereas 14 (58%) intubations with a box took over 1 min and 4 (17%) took over 2 min (including one failure). Without an aerosol box, all anaesthetists obtained first-pass success. With the early-generation and latest-generation boxes, 9 (75%) and 10 (83%) participants obtained first-pass success, respectively.

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

“…On the other hand, our results contradict those from a recent study performed by 12 anesthesiologists, which reported an intubation time of 42.9 [32.9-46.9] s without the box, 82.1 [45.1-98.3] s with the original box, and 52. 4 [43.1-70.3] s with the modi ed box [16]. The shorter intubation time in our study may be due to familiarity with the device and manikin through training.…”

“…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.…”

“…We enrolled 37 personnel (11 women and 26 men) with 12 [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] years of anesthesia and intensive care experience; all their records were incorporated into the nal analysis (Figure 1). (P=0.247).…”

“…A 7.0-mm tracheal tube with a stylet, angled by each participant, was used. Although some arrangements have been reported [16,17], we created and used an acrylic box based on the original version of the report [10].…”

“…This box was also expected to be useful in situations where higher-level personal protective equipment (PPE), such as the medical protective head hood and powered air-purifying respirators is unavailable [13,14]. However, simulation studies with a relatively small sample size (1-12 personnel) and a report involving ve patients have shown that tracheal intubation in the box can be challenging because it restricts hand movements [11,[14][15][16].…”