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

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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. One breach of personal protective equipment occurred using the early‐generation box and seven breaches occurred using the latest‐generation box. Aerosol boxes may increase intubation times and therefore expose patients to the risk of hypoxia. They may cause damage to conventional personal protective equipment and therefore place clinicians at risk of infection. Further research is required before these devices can be considered safe for clinical use.

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Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

Neeltje van Doremalen, Trenton Bushmaker, Dylan H Morris … (2021)

To the Editor: A novel human coronavirus that is now named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (formerly called HCoV-19) emerged in Wuhan, China, in late 2019 and is now causing a pandemic. 1 We analyzed the aerosol and surface stability of SARS-CoV-2 and compared it with SARS-CoV-1, the most closely related human coronavirus. 2 We evaluated the stability of SARS-CoV-2 and SARS-CoV-1 in aerosols and on various surfaces and estimated their decay rates using a Bayesian regression model (see the Methods section in the Supplementary Appendix, available with the full text of this letter at NEJM.org). SARS-CoV-2 nCoV-WA1-2020 (MN985325.1) and SARS-CoV-1 Tor2 (AY274119.3) were the strains used. Aerosols (<5 μm) containing SARS-CoV-2 (105.25 50% tissue-culture infectious dose [TCID50] per milliliter) or SARS-CoV-1 (106.75-7.00 TCID50 per milliliter) were generated with the use of a three-jet Collison nebulizer and fed into a Goldberg drum to create an aerosolized environment. The inoculum resulted in cycle-threshold values between 20 and 22, similar to those observed in samples obtained from the upper and lower respiratory tract in humans. Our data consisted of 10 experimental conditions involving two viruses (SARS-CoV-2 and SARS-CoV-1) in five environmental conditions (aerosols, plastic, stainless steel, copper, and cardboard). All experimental measurements are reported as means across three replicates. SARS-CoV-2 remained viable in aerosols throughout the duration of our experiment (3 hours), with a reduction in infectious titer from 103.5 to 102.7 TCID50 per liter of air. This reduction was similar to that observed with SARS-CoV-1, from 104.3 to 103.5 TCID50 per milliliter (Figure 1A). SARS-CoV-2 was more stable on plastic and stainless steel than on copper and cardboard, and viable virus was detected up to 72 hours after application to these surfaces (Figure 1A), although the virus titer was greatly reduced (from 103.7 to 100.6 TCID50 per milliliter of medium after 72 hours on plastic and from 103.7 to 100.6 TCID50 per milliliter after 48 hours on stainless steel). The stability kinetics of SARS-CoV-1 were similar (from 103.4 to 100.7 TCID50 per milliliter after 72 hours on plastic and from 103.6 to 100.6 TCID50 per milliliter after 48 hours on stainless steel). On copper, no viable SARS-CoV-2 was measured after 4 hours and no viable SARS-CoV-1 was measured after 8 hours. On cardboard, no viable SARS-CoV-2 was measured after 24 hours and no viable SARS-CoV-1 was measured after 8 hours (Figure 1A). Both viruses had an exponential decay in virus titer across all experimental conditions, as indicated by a linear decrease in the log10TCID50 per liter of air or milliliter of medium over time (Figure 1B). The half-lives of SARS-CoV-2 and SARS-CoV-1 were similar in aerosols, with median estimates of approximately 1.1 to 1.2 hours and 95% credible intervals of 0.64 to 2.64 for SARS-CoV-2 and 0.78 to 2.43 for SARS-CoV-1 (Figure 1C, and Table S1 in the Supplementary Appendix). The half-lives of the two viruses were also similar on copper. On cardboard, the half-life of SARS-CoV-2 was longer than that of SARS-CoV-1. The longest viability of both viruses was on stainless steel and plastic; the estimated median half-life of SARS-CoV-2 was approximately 5.6 hours on stainless steel and 6.8 hours on plastic (Figure 1C). Estimated differences in the half-lives of the two viruses were small except for those on cardboard (Figure 1C). Individual replicate data were noticeably “noisier” (i.e., there was more variation in the experiment, resulting in a larger standard error) for cardboard than for other surfaces (Fig. S1 through S5), so we advise caution in interpreting this result. We found that the stability of SARS-CoV-2 was similar to that of SARS-CoV-1 under the experimental circumstances tested. This indicates that differences in the epidemiologic characteristics of these viruses probably arise from other factors, including high viral loads in the upper respiratory tract and the potential for persons infected with SARS-CoV-2 to shed and transmit the virus while asymptomatic. 3,4 Our results indicate that aerosol and fomite transmission of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (depending on the inoculum shed). These findings echo those with SARS-CoV-1, in which these forms of transmission were associated with nosocomial spread and super-spreading events, 5 and they provide information for pandemic mitigation efforts.

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Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic

Tait Shanafelt, Jonathan A. Ripp, Mickey Trockel (2020)

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Staff safety during emergency airway management for COVID-19 in Hong Kong

Jonathan Cheung, Lap Tin Ho, Justin Cheng … (2020)

Medical professionals caring for patients with coronavirus disease 2019 (COVID-19) are at high risk of contracting the infection. 1 Aerosol-generating procedures, such as non-invasive ventilation (NIV), high-flow nasal cannula (HFNC), bag-mask ventilation, and intubation are of particularly high risk. 2 We hereby describe the approach of our local intensive care unit (North District Hospital, Sheung Shui, Hong Kong) to managing the risks to health-care staff, while maintaining optimal and high-quality care. All medical personnel involved in the management of patients with suspected COVID-19 must adhere to airborne precautions, hand hygiene, and donning of personal protective equipment. All aerosol-generating procedures should be done in an airborne infection isolation room. Double-gloving, as a standard practice at our unit, might provide extra protection and minimise spreading via fomite contamination to the surrounding equipment after intubation. 3 An experiment with a mannikin showed that NIV or HFNC, when well applied with an optimal fit, only lead to minimal dispersion of exhaled air. 4 However, the specific NIV and HFNC models and modes tested in the study are not universally used across all hospitals. Therefore, to avoid confusion and potential harm, we do not recommend using NIV or HFNC until the patient is cleared of COVID-19. Airway devices providing 6 L/min or more of oxygen are considered high-flow 5 and we discourage their use if an airborne infection isolation room is unavailable. We recommend that endotracheal intubation is done by an expert specialised in the procedure, and early intubation should be considered in a patient with deteriorating respiratory condition. For all cases, backup airway plans should be ready. We recommend avoiding bag mask ventilation for as long as possible; and optimising preoxygenation with non-aerosol-generating means. Methods include the bed-up-head-elevated position, airway manoeuvres, use of a positive end expiratory pressure valve, and airway adjuncts. If manual bagging is required, we suggest gentle ventilation via a supraglottic device instead of bag mask ventilation. Although no robust evidence is available to show that the use of supraglottic devices are less aerosol-generating than BMV, the devices are easy to insert and can achieve sufficient seal pressure. They also help to spare manpower and thus reduce staff exposure. Furthermore, many newer generation supraglottic devices provide a conduit for unassisted intubation. To monitor the pattern of ventilation, a continuous waveform capnography monitoring device should be used; an advantage of this being that a correct waveform accurately reflects correct endotracheal tube placement. Furthermore, physiologically, it might give clues on the adequacy of the seal when using supraglottic devices. Rapid sequence induction is the technique of choice for emergency intubation. Some operators prefer rocuronium over suxamethonium for its longer half-life, which effectively prevents coughing or vomiting that might occur when the shorter acting muscle relaxant subsides after an unsuccessful first attempt. When rocuronium is used, a full 1·2 mg/kg intravenous dose should be administered to achieve a similar onset time to suxamethonium. Once an endotracheal tube is inserted, its cuff should be inflated immediately to avoid leakage. The endotracheal tube should be connected to the ventilator via a filter and a waveform capnography monitoring device, with ventilation only started after pilot balloon inflation is confirmed. The capnography monitoring device waveform can subsequently confirm the correct positioning of the endotracheal tube. Only then should the physician exclude bronchial intubation by five-point auscultation. © 2020 Conceptual Images/Science Photo Library 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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Contributors

J. L. Begley: Role: Registrar, Anaesthetistbegley@doctorbegley.com.au

K. E. Lavery: Role: Registrar

C. P. Nickson: Role: Intensive Care Physician and Innovation Lead, Adjunct Clinical Associate Professor

D. J. Brewster: Role: Associate Professor, Deputy Director

Journal

Journal ID (nlm-ta): Anaesthesia

Journal ID (iso-abbrev): Anaesthesia

Journal ID (doi): 10.1111/(ISSN)1365-2044

Journal ID (publisher-id): ANAE

Title: Anaesthesia

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Print): 0003-2409

ISSN (Electronic): 1365-2044

Publication date (Electronic): 01 June 2020

Electronic Location Identifier: 10.1111/anae.15115

Affiliations

[ ¹ ] Intensive Care Unit Cabrini Hospital Malvern Vic Australia

[ ² ] 2nd General Health Battalion Australian Army Brisbane QLD Australia

[ ³ ] Alfred Health Melbourne Vic Australia

[ ⁴ ] School of Public Health and Preventative Medicine Monash University Melbourne Vic Australia

[ ⁵ ] Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Vic Australia

Author notes

[*] [* ] Correspondence to: J. Begley

Email: begley@ 123456doctorbegley.com.au

Article

Publisher ID: ANAE15115

DOI: 10.1111/anae.15115

PMC ID: 7273017

PubMed ID: 32397008

SO-VID: 719b97d9-e99a-4319-90d5-6e344059fec0

License:

This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

History

Date accepted : 07 May 2020

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Figures: 3, Tables: 2, Pages: 8, Words: 10316

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details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.3 mode:remove_FC converted:05.06.2020

ScienceOpen disciplines: Anesthesiology & Pain management

Keywords: aerosol box,barrier device,covid‐19,intubation,personal protective equipment,ppe,rapid sequence induction,rsi

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ScienceOpen disciplines: Anesthesiology & Pain management

Keywords: aerosol box, barrier device, covid‐19, intubation, personal protective equipment, ppe, rapid sequence induction, rsi

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

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Novel Coronavirus Disease COVID-19

Most cited references 27

Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic

Staff safety during emergency airway management for COVID-19 in Hong Kong

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