Abstract
BackgroundThe challenges posed by the spread of COVID-19 disease through aerosols have compelled anesthesiologists to modify their airway management practices. Devices such as barrier boxes are being considered as potential adjuncts to full PPE’s to limit the aerosol spread. Usage of the barrier box raises concerns of delay in time to intubate (TTI). We designed our study to determine if using a barrier box with glidescope delays TTI within acceptable parameters to make relevant clinical conclusions.MethodsSeventy-eight patients were enrolled in this prospective non-inferiority controlled trial and were randomly allocated to either group C (without the barrier box) or the study group BB (using barrier box). The primary measured endpoint is time to intubate (TTI), which is defined as time taken from loss of twitches confirmed with a peripheral nerve stimulator to confirmation of end-tidal CO 2. 15 s was used as non-inferiority margin for the purpose of the study. We used an unpaired two-sample single-sided t-test to test our non- inferiority hypothesis (H 0: Mean TTI diff ≥15 s, H A: Mean TTI diff < 15 s). Secondary endpoints include the number of attempts at intubation, lowest oxygen saturation during induction, and the need for bag-mask ventilation.ResultsMean TTI in group C was 42 s (CI 19.2 to 64.8) vs. 52.1 s (CI 26.1 to 78) in group BB. The difference in mean TTI was 10.1 s (CI -∞ to 14.9). We rejected the null hypothesis and concluded with 95% confidence that the difference of the mean TTI between the groups is less than < 15 s (95% CI -∞ to 14.9,p = 0.0461). Our induction times were comparable (67.7 vs. 65.9 s).100% of our patients were intubated on the first attempt in both groups. None of our patients needed rescue breaths.ConclusionsWe conclude that in patients with normal airway exam, scheduled for elective surgeries, our barrier box did not cause any clinically significant delay in TTI when airway manipulation is performed by well-trained providers.The study was retrospectively registered at clinicaltrials.gov (NCT04411056) on May 27, 2020.
Highlights
The challenges posed by the spread of COVID-19 disease through aerosols have compelled anesthesiologists to modify their airway management practices
Anesthesia Patient Safety Foundation (APSF) and American Society of Anesthesiologists (ASA) recommends as an optimal practice that all anesthesia professionals should utilize full personal protective equipment (PPE) appropriate for aerosolgenerating procedures for all patients when working near the airway and use of video-laryngoscopy when possible in suspected patients [2]
Inability to consent or cooperate, children, pregnant women, patients with severe cardiopulmonary compromise, ASA physical status 4 and 5, Body Mass Index (BMI) > 35, known or anticipated difficult airway, patients with positive COVID status or unknown COVID status were excluded from the study
Summary
The challenges posed by the spread of COVID-19 disease through aerosols have compelled anesthesiologists to modify their airway management practices. Clinicians have been compelled to improvise and use protective barrier enclosures during airway manipulation to minimize aerosol exposure to operating room personnel [4]. Novel devices such as an “Intubation barrier box” are being mentioned as viable options when used during airway management. We re-designed the barrier box to possibly provide additional protection to the personnel while safely providing airway management to our patients [5]. This is the first clinical study to evaluate the impact of using the re-designed barrier box during airway management and its feasibility in routine clinical practice during this pandemic era
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