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  Table of Contents  
Year : 2020  |  Volume : 57  |  Issue : 4  |  Page : 502-504

Barrier devices for aerosol-generating procedure during COVID-19 pandemic

Department of Onco-Anaesthesia and Palliative Medicine, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Date of Submission28-Jun-2020
Date of Decision01-Jul-2020
Date of Acceptance10-Sep-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Vinod Kumar
Department of Onco-Anaesthesia and Palliative Medicine, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_702_20

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How to cite this article:
Kumar V, Gupta N. Barrier devices for aerosol-generating procedure during COVID-19 pandemic. Indian J Cancer 2020;57:502-4

How to cite this URL:
Kumar V, Gupta N. Barrier devices for aerosol-generating procedure during COVID-19 pandemic. Indian J Cancer [serial online] 2020 [cited 2021 Jan 18];57:502-4. Available from:

Coronavirus disease 2019 (COVID-19) epidemic has resulted in patients with varying severity of respiratory problems. Anesthetists are frequently involved in patient's airway management, resuscitation, and critical care. The risk posed to health care worker/s (HCW) during aerosol-generating procedure/s (AGP) such as intubation and extubation is significant, especially when compounded by the limited availability of personal protective equipment (PPE).[1] Improper precautions during AGP may increase the risk of infections to HCW. The most important steps to prevent infections are hand hygiene, proper use of PPE, and proper doffing off after the procedure.

Though the risk of infection spread during intubation is well documented, extubation is as risky, and coughing during extubation may additionally lead to aerosol generation and pose risks to HCW. The ideal method to mitigate such risk is the presence of negative pressure rooms for such AGP. Deep extubation is suggested in guidelines to reduce cough, and several drugs like lignocaine, dexmedetomidine, remifentanil, and fentanyl have also been tried to reduce the cough.[2],[3] However, these measures may reduce the incidence of cough but may not eliminate it.

The need for barrier device arises to reduce the exposure of HCW to aerosols during the AGP. An ideal barrier device should protect the user from aerosols by physical barrier, allow assessment of oxygenation during AGP, have a system to inactivate viral load that may be generated during the AGP, and is ergonomically easy to operate during airway manipulation.

In this issue, Bakshi et al. have created a barrier using green transparent plastic drape which was spread over two surgical screen holders and these were attached to the head end of the operating table.[4] However, there are some concerns with the use of this device like it may hamper the visualization of the airway especially if the patient requires re-intubation. Also, the anesthesiologists may get self-contaminated and improper disposal of the plastic cover sheet can lead to cross-contamination of the health care workers.

  Barrier Devices With Their Pros and Cons Top

The design of barrier devices for intubation and AGP is continuously evolving. Initially, carton boxes with transparent drapes followed by acrylic boxes were used for AGP.[5] Matava et al. have used clear plastic drape in three panels with the first layer placed over the linen and operating table and second layer placed over the neck and chest and third layer covered head till mid-sternum.[6] Plastic drape sheet is disposable, inexpensive, and has less restriction to hand movements.

The acrylic barrier box having two circular arm ports for airway handling protects providers from aerosolized particulate. It helps in reducing droplet dispersal and a direct splash of secretions on the face of laryngoscopists. However, the aerosol boxes have their limitations like inappropriate cleaning may lead to cross-contamination, it is difficult to use in an agitated and uncooperative patient, ergonomically cumbersome to operate in difficult airway scenario, possible contamination of assistants during equipment handover, and urgent removal of the box during airway crisis.[7] We use a basic version of the barrier device in our setup that is cleaned in between each use with 70% ethyl alcohol or freshly prepared 1% sodium hypochlorite solution applied for at least 10 minutes and then cleaned with a damp cloth [Figure 1] and [Figure 2]. Intubation Aerosol Containment System (IACS) is made up of rigid polycarbonate having integrated sleeves and plastic drapes which offer superior protection to laryngoscopist and assistant from aerosols. It contains two circular arm ports with flexible extension sleeves for airway handling.[8] A thin, plastic drape is attached to the superior and lateral edges of the box for additional protection from aerosols.[9] Balloon for Aerosol Protection (BAP) is a big balloon with built-in glove covers. It is an airtight protective device in which the patient can move his head and laryngoscopist can do airway manipulation at will. Since it is a closed device; there is a possibility of CO2 retention or hypoxia if used for a prolonged duration. Operators should tear off the balloon if the patient requires re-intubation or other respiratory support.[10] The use of adjuncts and fiberoptic bronchoscope may be difficult in most of the available intubation boxes due to the limitation of the space available for manipulation of this equipment. Some acrylic boxes have a special port for bougie and fiberoptic bronchoscope for managing the difficult airway.[11] However, there are many reports where the intubation box had to be removed to manage the airway in a potentially difficult case. Acrylic box with an in-situ portable chamber for negative airflow isolation mimic the negative pressure operation theaters and have also been developed and used during the COVID-19 pandemic.[12]
Figure 1: Acrylic box for aerosol containment during intubation. A-Port for laryngoscopist's hand. B-Port for fiberoptic

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Figure 2: Aerosol box showing ports with hand sleeve for laryngoscopist and assistant. (Courtesy Dr. J Balavenkat)

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People have also tried make-shift devices like an orthopedic hood for AGP.[13] However, these may give a false sense of security to the laryngoscopist and may increase the exposure to aerosols generated during the procedures. Despite the availability of a wide variety of intubation boxes, there is no study that showed the effectiveness of one over the other. In the absence of robust literature, a recommendation cannot be given for specific use of a particular make of the device.

The use of barrier devices to prevent exposure should be considered to protect our HCW during AGP. However, these barriers are not a substitute for standard PPE and universal precautions. In absence of negative pressure rooms for management of COVID-19 during AGP, several improvised barrier devices with inbuilt suction ensuring requisite air circulation that mitigate aerosolization should be preferred over the makeshift arrangements. We need to train our HCW in proper usage and cleaning of these barrier devices during high-risk procedures to ensure their safety.

  References Top

Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One 2012;7:e35797.  Back to cited text no. 1
Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia 2020;75:785-99.  Back to cited text no. 2
Tung A, Fergusson NA, Ng N, Hu V, Dormuth C, Griesdale DEG. Medications to reduce emergence coughing after general anaesthesia with tracheal intubation: A systematic review and network meta-analysis. Br J Anaesth 2020;124:480-95.  Back to cited text no. 3
Bakshi SG, Trivedi B, Patil VP. Use of protective partition during extubation during COVID-19 pandemic. Indian J Cancer [In this issue].  Back to cited text no. 4
Lai YY, Chang CM. A carton-made protective shield for suspicious/confirmed COVID-19 intubation and extubation during surgery. Anesth Analg. 2020:10.1213/ANE.0000000000004869.   Back to cited text no. 5
Matava CT, Yu J, Denning S. Clear plastic drapes may be effective at limiting aerosolisation and droplet spray during extubation: Implications for COVID-19. Can J Anaesth 2020;67:902-4.  Back to cited text no. 6
Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier enclosure during endotracheal intubation. N Engl J Med 2020;382:1957-8.  Back to cited text no. 7
Maniar A, Jagannathan B. The aerosol box. J Anaesthesiol Clin Pharmacol 2020;36(Suppl S1):141-3  Back to cited text no. 8
Gore RK, Saldana C, Wright DW, Klein AM. Intubation containment system for improved protection from aerosolized particles during airway management. IEEE J Transl Eng Health Med 2020;8:1600103.  Back to cited text no. 9
Hirose K, Uchida K, Umezu S. Airtight, flexible, disposable barrier for extubation. J Anesth 2020:1-2.   Back to cited text no. 10
Begley JL, Lavery KE, Nickson CP, Brewster DJ. The aerosol box for intubation in coronavirus disease 2019 patients: An in-situ simulation crossover study. Anaesthesia 2020;75:1014-21.  Back to cited text no. 11
Cubillos J, Querney J, Rankin A, Moore J, Armstrong K. A multipurpose portable negative airflow isolation chamber for aerosol-generating procedures during the COVID-19 pandemic. Br J Anaesth 2020;125:e179-81.  Back to cited text no. 12
Wills TT, Zuelzer WA, Tran BW. Utilization of an orthopedic hood as personal protective equipment for intubation of coronavirus patients: A brief technical report. Geriatr Orthop Surg Rehabil 2020;11:2151459320930554.  Back to cited text no. 13


  [Figure 1], [Figure 2]


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