To the Editor The coronavirus disease (COVID-19) pandemic has led to awareness of the heightened risk for the anesthesia provider. A recent joint position statement by the American Society of Anesthesiologists, the Anesthesia Patient Safety Foundation, the American Academy of Anesthesiologist Assistants, and the American Association of Nurse Anesthetists recommended as optimal practice that all anesthesia professionals utilize personal protective equipment (PPE) appropriate for aerosol-generating procedures for all patients. 1 However, there remains a shortage of PPE, and some institutions still limit the use of N95 respirators and powered air-purifying respirators (PAPRs) for confirmed COVID cases. Because of this scarcity, physical barriers have been proposed as a means of protecting personnel during airway instrumentation. The first “aerosol box” was designed and shared on social media by a Taiwanese anesthesiologist, Dr Hsien-Yung Lai. 2 This transparent plastic cube was designed to allow the patient to lie at the head of the operating room table, separated from the anesthesia provider by a clear barrier, with 2circular openings at the superior end to allow the clinician’s hands to pass through and perform airway manipulation. Canelli et al 3 recently demonstrated that a simulated cough resulted in contamination of the inner surface of the box and the laryngoscopist’s gloves and gowned forearms, as opposed to pollution of the operating room environment more than 2 m away when no barrier was utilized. With current lack of widespread point-of-care testing, there remains the risk of transmission from asymptomatic carriers. 4 Moreover, during surgery, other aerosol-generating procedures might be required intraoperatively and at emergence, including the nebulization of inhaled beta-agonist, emergent reintubation, oropharyngeal suctioning, extubation of the endotracheal tube, and delivery of high-flow oxygen. These same measures are also performed during monitored anesthesia care (MAC) cases. In addition, certain types of procedures typically done under MAC, such as upper endoscopy, can cause a high incidence of coughing. Depending on the stability of the structure, intubation shields may be left at the head of the operating room table for the duration of the surgical procedure as opposed to immediately removed after successful endotracheal intubation. A small clear drape can be used to cover the ports while allowing the anesthesia provider ready access to the patient’s airway (Figure). At the end of the case, these physical barriers can be easily cleaned with spray disinfectant and/or germicidal disposable wipes. As with all novel techniques, there remains a learning curve to familiarize oneself for use in everyday practice. Finally, in certain cases, the patient’s body habitus, anatomical location of the surgery, or surgical positioning may preclude the use of the intubation shield. Figure. A clear drape covers the 2 circular openings of the intubation shield during surgery. With a limited supply of PPE, the intubation shield or other barrier devices could be a reasonable cost-effective strategy to help protect anesthesia professionals and other surgical personnel, and their usage should be considered for all cases currently being performed in the operating room. ACKNOWLEDGMENTS The author thanks Collectible Grading Authority (Norcross, GA) for the donation of the intubation shields. Phil B. Tsai, MD, MPH Department of Anesthesiology Rancho Los Amigos National Rehabilitation Center Downey, California ptsai@dhs.lacounty.gov
