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      Opening Pandora’s Box: Aerosol boxes and barrier enclosures for airway management in COVID-19 patients – a scoping review and narrative synthesis

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          Exposure of healthcare providers to SARS-CoV-2 is a significant safety concern during COVID-19 pandemic, requiring contact/droplet/airborne precautions. Due to global shortages, limited availability of personal protective equipment has motivated the development of barrier-enclosure systems such as aerosol boxes, plastic drapes, and similar protective systems .

          We examined the available evidence and scientific publications about barrier-enclosure systems for airway management in suspected/confirmed COVID-19 patients. Medline/EMBASE/Google Scholar databases (December 1/2019 - May 27/2020) were searched for all articles on barrier enclosures for airway management in COVID-19, including references and websites. All sources were reviewed by a panel of experts using a Delphi method with a modified nominal-group technique.


          Fifty-two articles were reviewed for their results and level of evidence regarding barrier device feasibility, advantages, protection against droplets and aerosols, effectiveness, safety, ergonomics, and cleaning/disposal.

          The majority of analysed papers were expert opinion, small case-series, technical descriptions, small-sample simulation studies, and pre-print proofs.


          The use of barrier-enclosure devices adds to the complexity of airway procedures with potential adverse consequences, especially during airway emergencies. Concerns include limitations on the ability to perform airway interventions and the aid that can be delivered by an assistant, patient injuries, compromise of PPE integrity, lack of evidence for added protection of healthcare providers including secondary aerosolization upon barrier removal, and lack of cleaning standards.

          Enclosure barriers for airway management are no substitute for adequate PPE, and their use should be avoided until adequate validation studies can be reported.

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          Most cited references 63

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          The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

          Novel coronavirus 2019 is a single-stranded, ribonucleic acid virus that has led to an international pandemic of coronavirus disease 2019. Clinical data from the Chinese outbreak have been reported, but experiences and recommendations from clinical practice during the Italian outbreak have not. We report the impact of the coronavirus disease 2019 outbreak on regional and national healthcare infrastructure. We also report on recommendations based on clinical experiences of managing patients throughout Italy. In particular, we describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non-technical aspects of caring for patients diagnosed with coronavirus disease 2019. Only through planning, training and team working will clinicians and healthcare systems be best placed to deal with the many complex implications of this new pandemic.
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            Visualizing Speech-Generated Oral Fluid Droplets with Laser Light Scattering

            To the Editor: Aerosols and droplets generated during speech have been implicated in the person-to-person transmission of viruses, 1,2 and there is current interest in understanding the mechanisms responsible for the spread of Covid-19 by these means. The act of speaking generates oral fluid droplets that vary widely in size, 1 and these droplets can harbor infectious virus particles. Whereas large droplets fall quickly to the ground, small droplets can dehydrate and linger as “droplet nuclei” in the air, where they behave like an aerosol and thereby expand the spatial extent of emitted infectious particles. 2 We report the results of a laser light-scattering experiment in which speech-generated droplets and their trajectories were visualized. The output from a 532-nm green laser operating at 2.5-W optical power was transformed into a light sheet that was approximately 1 mm thick and 150 mm tall. We directed this light sheet through slits on the sides of a cardboard box measuring 53×46×62 cm. The interior of the box was painted black. The enclosure was positioned under a high-efficiency particulate air (HEPA) filter to eliminate dust. When a person spoke through the open end of the box, droplets generated during speech traversed approximately 50 to 75 mm before they encountered the light sheet. An iPhone 11 Pro video camera aimed at the light sheet through a hole (7 cm in diameter) on the opposite side of the box recorded sound and video of the light-scattering events at a rate of 60 frames per second. The size of the droplets was estimated from ultrahigh-resolution recordings. Video clips of the events while the person was speaking, with and without a face mask, are available with the full text of this letter at We found that when the person said “stay healthy,” numerous droplets ranging from 20 to 500 μm were generated. These droplets produced flashes as they passed through the light sheet (Figure 1). The brightness of the flashes reflected the size of the particles and the fraction of time they were present in a single 16.7-msec frame of the video. The number of flashes in a single frame of the video was highest when the “th” sound in the word “healthy” was pronounced (Figure 1A). Repetition of the same phrase three times, with short pauses in between the phrases, produced a similar pattern of generated particles, with peak numbers of flashes as high as 347 with the loudest speech and as low as 227 when the loudness was slightly decreased over the three trials (see the top trace in Figure 1A). When the same phrase was uttered three times through a slightly damp washcloth over the speaker’s mouth, the flash count remained close to the background level (mean, 0.1 flashes); this showed a decrease in the number of forward-moving droplets (see the bottom trace in Figure 1A). We found that the number of flashes increased with the loudness of speech; this finding was consistent with previous observations by other investigators. 3 In one study, droplets emitted during speech were smaller than those emitted during coughing or sneezing. Some studies have shown that the number of droplets produced by speaking is similar to the number produced by coughing. 4 We did not assess the relative roles of droplets generated during speech, droplet nuclei, 2 and aerosols in the transmission of viruses. Our aim was to provide visual evidence of speech-generated droplets and to qualitatively describe the effect of a damp cloth cover over the mouth to curb the emission of droplets.
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              Barriers and facilitators to healthcare workers’ adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis

              This review is one of a series of rapid reviews that Cochrane contributors have prepared to inform the 2020 COVID-19 pandemic. When new respiratory infectious diseases become widespread, such as during the COVID-19 pandemic, healthcare workers' adherence to infection prevention and control (IPC) guidelines becomes even more important. Strategies in these guidelines include the use of personal protective equipment (PPE) such as masks, face shields, gloves and gowns; the separation of patients with respiratory infections from others; and stricter cleaning routines. These strategies can be difficult and time-consuming to adhere to in practice. Authorities and healthcare facilities therefore need to consider how best to support healthcare workers to implement them.

                Author and article information

                Role: Consultant
                Role: Professor of Anaesthesiology
                Role: Associate Professor and Lead: Fellowship in Airway and Thoracic Anaesthesia
                Role: Professor of Anaesthesiology, Professor
                Role: Clinical Professor Anaesthesiology
                Br J Anaesth
                Br J Anaesth
                BJA: British Journal of Anaesthesia
                British Journal of Anaesthesia. Published by Elsevier Ltd.
                3 September 2020
                3 September 2020
                [1 ]Anaesthesia and Intensive Care, Policlinico San Marco University Hospital, Catania, Italy
                [2 ]Department of Anesthesiology, Yale School of Medicine
                [3 ]Department of Anaesthesia and Perioperative Medicine, University of Cape Town, South Africa
                [4 ]Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
                [5 ]Department of Anaesthesiology, University of Florida/NFSGVHS, USA
                [6 ]Medical Education, School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
                Author notes
                []Corresponding author. Massimiliano Sorbello Department of Emergency Medicine, Anaesthesia and Intensive Care, Policlinico Vittorio Emanuele San Marco University Hospital, Viale C.A. Ciampi, 95100, Catania, Italy +393496277107 , .
                © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

                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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