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Year : 2020  |  Volume : 64  |  Issue : 14  |  Page : 153-154  

Barrier enclosure for airway management in COVID-19 pandemic

1 Department of Anaesthesiology, Regional Cancer Centre, Chackai, Trivandrum, Kerala, India
2 Department of Plastic and Reconstructive Surgery, Cosmetiq Clinic, Chackai, Trivandrum, Kerala, India
3 Department of Anaesthesiology, Cosmetiq Clinic, Chackai, Trivandrum, Kerala, India

Date of Submission20-Apr-2020
Date of Decision25-Apr-2020
Date of Acceptance06-May-2020
Date of Web Publication23-May-2020

Correspondence Address:
Dr. Karthika Asokan
Department of Anaesthesiology, Regional Cancer Centre, Trivandrum, Kerala - 695 011
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_413_20

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How to cite this article:
Asokan K, Babu B, Jayadevan A. Barrier enclosure for airway management in COVID-19 pandemic. Indian J Anaesth 2020;64, Suppl S2:153-4

How to cite this URL:
Asokan K, Babu B, Jayadevan A. Barrier enclosure for airway management in COVID-19 pandemic. Indian J Anaesth [serial online] 2020 [cited 2020 Oct 28];64, Suppl S2:153-4. Available from: https://www.ijaweb.org/text.asp?2020/64/14/153/284911


The novel coronavirus pandemic is taking a tremendous toll on the lives of health care workers. The asymptomatic clinical presentation of coronavirus disease 2019 (COVID-19)[1] poses high risk during intubation and extubation when enormous droplet scatter is anticipated. Centres for Disease Control and Prevention recommends surface disinfection rather than fumigation or wide-area spraying of contaminated surfaces.[2] In view of the exponential rise in the number of COVID-19 cases, there are chances of improper disinfection of operating rooms (OR)/intensive care units (ICU). So we need additional barriers to reduce surface contamination and allow safe reuse of personal protective equipment (PPE) under circumstances of diminishing PPE supply.

The concept of aerosol box was first formulated by Dr. Lai Hsien-yung, an anaesthesiologist from Taiwan.[3] The efficacy of the box in reducing droplet scatter has been studied in a Mannequin with the simulation of cough.[4] The name aerosol box is however a misnomer, as there cannot be absolute containment of aerosols generated during airway interventions. The original design is a 50 × 50 × 40 cm box with two armholes of 10 cm diameter. The side panels are rectangular and there is no front panel.[5]

The box we made has a front panel, upper surface, intubator surface with two armholes (12 cm diameter), and two side panels with C-shaped curves [Figure 1]. The box is made of high-quality 4 mm transparent acrylic sheet with a gross weight of 3900 g. A single sheet was used to make the front panel, upper surface, and intubator surface, creating a smooth curve at the bends to avoid aberrations and blind spots. [Figure 2] As the average width of OR table is 50 cm, the reduction in base-width from 50 cm to 48 cm offered more stability and avoided fall with slight movement when using in OR. C-shaped curves helped to make laryngoscopy easy in obese individuals, as they could rest their arms comfortably on arm boards allowing the breasts to fall laterally. The anaesthesia circuit was taken inside from below the front panel, whereas the side curves gave sufficient space for the assistant to apply cricoid pressure, pass the endotracheal tube, remove stylet, etc. In obese patients, to align the external auditory meatus in the same horizontal plane as the sternal notch, we elevated the backplate of OR table by 25 degrees[6] and horizontalised the head rest. The box could be conveniently placed under such circumstances. The same might not be possible in morbidly obese patients. Upon our experience in more than fifty patients, including critically ill, we found laryngoscopy convenient with both video laryngoscope and Macintosh laryngoscope. Whenever airway difficulty was encountered, the box was lifted off the patient by the assistant and placed bedside. As there is an inevitable restriction in the physician's range of motion during the procedure, we suggest simulation-based training for clinicians before using it in OR/ICU so as to increase operator familiarity. The box has minimal corners and bends and can be easily disinfected by wiping with 0.5% hypochlorite. There is a possibility of scatter of droplets over assistant through the gap below the front panel, and to avoid this we suggest using OR drapes to cover the open portion. [Figure 2]
Figure 1: Dimensions of the aerosol box

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Figure 2: Picture shows aerosol box kept on OR table after covering open portion with a drape. Upper smooth curves can be seen

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Although there cannot be complete protection from infected aerosols, droplet contamination can be considerably reduced when airway interventions are done with the aerosol box.[4] Its benefit during the intubation of critically ill patients needs more validation. We feel this enclosure device can protect health care workers when treating patients suffering from infections that are transmitted via respiratory droplets, apart from COVID-19.

Authors' contributions

All authors contributed equally.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Meng H, Xiong R, He R, Lin W, Hao B, Zhang L,et al. CT imaging and clinical course of asymptomatic cases with COVID-19 pneumonia at admission in Wuhan, China. J Infect 2020. pii: S0163-4453(20)30211-5. doi: 10.1016/j.jinf. 2020.04.004. [Epub ahead of print]  Back to cited text no. 1
Centre for Disease control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. Available from: https://www.cdc.gov/coronavir us/2019-ncov/infection-control/control-recommend tions.html. [Last accessed on 2020 Apr].  Back to cited text no. 2
Everington K. Taiwanese doctor invents device to protect US doctors against coronavirus. Taiwan News. March 23, 2020. (https://www.taiwannew s.com.tw/en/news/3902435).  Back to cited text no. 3
Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier enclosure during endotracheal intubation.N Engl J Med 2020 Apr 3. doi: 10.1056/NEJMc2007589. [Epub ahead of print]  Back to cited text no. 4
Lai HY, Design A. (2020) Aerosol box-design. [online] Sites.google.com. Available from: https://sites.google.com/view/aeroso lbox/design [Last accessed on 2020 May 06].  Back to cited text no. 5
Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A,et al. Difficult airway society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115:827-48.  Back to cited text no. 6


  [Figure 1], [Figure 2]


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