A simple negative-pressure protective barrier for extubation of COVID-19 patients
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CORRESPONDENCE
A simple negative-pressure protective barrier for extubation of COVID-19 patients Orlando Hung, MD, FRCPC . David Hung, MD . Christopher Hung, BSc, PCP . Ronald Stewart, OC, ONS, MD, FACEP
Received: 11 May 2020 / Revised: 14 May 2020 / Accepted: 14 May 2020 Ó Canadian Anesthesiologists’ Society 2020
To the Editor, We read with interest the creative article recently published in the Journal by Matava et al. on how ‘‘Clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation’’.1 Recently, others have also suggested innovative barriers such as the ‘‘Aerosol Box’’,2 and the carton-made protective shield3 for tracheal intubation and extubation. While we appreciate these suggestions for protecting healthcare workers when they are managing the airway of patients with coronavirus disease (COVID-19), these barriers have limitations. Coughing during airway intervention, particularly during extubation, can generate droplets of various sizes.4 Although the barriers suggested by Matava and others1–3 may block the large droplets projected by coughing from landing on the airway practitioner’s face or body, the ‘‘smaller’’ droplet nuclei (\ 5 lm; i.e., ‘‘aerosols’’) will likely be suspended, drifting about in the air inside the barrier device. It is also likely that the water content of the small droplets will evaporate, making the droplets even smaller and allowing them to drift farther,4 and possibly escaping into the surrounding environment when the barrier is removed. Every effort should be made to
O. Hung, MD, FRCPC (&) Departments of Anesthesia, Surgery, and Pharmacology, Dalhousie University, Halifax, NS, Canada e-mail: [email protected] D. Hung, MD R. Stewart, OC, ONS, MD, FACEP Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada C. Hung, BSc, PCP Department of Anesthesia, Dalhousie University, Halifax, NS, Canada
mitigate this risk during airway intervention. Because availability of negative-pressure rooms is limited, and to reduce the risk of aerosol exposure during extubation in a non-negative-pressure environment, we have developed the following procedure, which is practical, simple, and affordable. Before extubation, and while the patient remains paralyzed, we place a clear plastic bag split along one side of its seam over the patient’s head so that the bag naturally forms a ‘‘tent’’ (Figure A). We then cut a small hole at its apex (Figure B). To prevent droplets from being exhaled from the lungs, the endotracheal tube (ETT) is clamped momentarily to allow its disconnection from the ventilation circuit and its end is inserted through the barrier tent’s hole. The bag is then sealed around the ETT (with tape or an elastic band) before being reconnected to the circuit (Figure C). The ETT clamp is then released. After anesthesia is terminated and paralysis reversed, the patient is fully awakened with the return of airway reflexes, the tape securing the ETT is loosened (Figure C), and the ETT cuff is deflated through the plastic cover
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