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Aerosol Box 2.0: Adjustments and Improvements Made in Mexico for Intubating Patients During the Coronavirus Disease 2019 Pandemic

López Hernández, Mercedes Nicté MD*; Álvarez Reséndiz, Gerardo Esteban MD, MSc; Galván Talamantes, Yazmin MD*; Lagarda Cuevas, Juan MD, MPH; Wilson-Manríquez, Eduardo A. MD§; Calva Ruiz, Diana Stephanie MD*; Ham Armenta, Cristian Irvin MD*

Author Information
doi: 10.1213/XAA.0000000000001273

Abstract

In Latin America, the health care systems are predominantly public, with high occupancy levels, but with limited technology and materials for patient care. These constraints force doctors to develop complementary strategies to improve personal protection in critical areas of the hospital (emergency departments, operating rooms, and intensive care units). Mexico is not the exception; the available resources are provided by a health care system limited by a low budget.

The justification for upgrading previously described “aerosol-limiting” intubation barriers was to improve our personal protection and reduce the exposure to the virus. We designed an isolation box that has ergonomic features that facilitates endotracheal intubation while avoiding contamination. Furthermore, it enables effective assistance by a nurse or resident when required and protects everyone in the room.

DISCUSSION

The Aerosol Box 2.0, a lightweight, crystalline acrylic box that works as a physical barrier against aerosol spreading, can easily be cleaned and disinfected (Table). It is an improved version of the one previously described in the literature.1 Like the original aerosol box, it consists of a transparent plastic chamber designed to cover the patient’s head and incorporating 2 circular access ports through which the clinician’s hands are passed to perform the airway procedure. It also has 2 lateral accesses so that tools can be passed to the provider who performs the intubation (Figure 1). There are clips to hold the suction device and video laryngoscope in place (Figure 2), and a bag for contaminated material after intubation (Figure 3). A belt to fasten the box to the operating table has been incorporated so that it does not move or fall during the procedure (Figure 4). In addition to these modifications, the Aerosol Box 2.0 has a superior angulation that allows the anesthesiologist to be physically closer to the patient without compromising safety and improves visualization of laryngoscopy and intubation. The design also includes a modification that allows adequate adaptation to the shoulder width of each patient (Figure 5). Complementary to the use of personal protective equipment (PPE), these improvements allow greater control of the materials used during intubation (Supplemental Digital Content, Video, http://links.lww.com/AACR/A336).

Table. - List of Supplies to Build an Aerosol Box 2.0
Item No. Part No. Material Quantity
1 Central body 3 mm clear acrylic 1
2 Left side cover 3 mm clear acrylic 1
3 Right side cover 3 mm clear acrylic 1
4 Disposable sealing patch 1/16” White nitrile rubber 3
5 Structural support 8 mm clear acrylic square bar 2
6 Top clips Command
White decorating clips (17026-ES)
3
7 Right side hooks Command
Small white wire hooks (GP067-16NA)
2
8 Lateral plate 20 GA steel 2
9 Aluminium screw postfemale ¼” aluminum screw post 4
10 Aluminium screw postmale ¼” aluminum screw post 4
11 Nylon strap right 1” nylon strap 1
12 Nylon strap left 1” nylon strap +1” metal cam buckle 1

Figure 1.
Figure 1.:
Two circular ports and lateral accesses.
Figure 2.
Figure 2.:
Clips to hold the ventilation circuit, suction device, and video laryngoscope.
Figure 3.
Figure 3.:
Clips to hold bag for contaminated material after intubation.
Figure 4.
Figure 4.:
A belt to fasten the box to the operating table has been incorporated so that it does not move or fall during the procedure.
Figure 5.
Figure 5.:
Aerosol Box 2.0 allows adequate adaptation to the shoulder width of each patient.

The coronavirus can be transmitted via aerosolization with spread to health care providers if barrier methods are not employed.1 Simulation of airway management has shown extensive viral contamination on the floor up to 1 m away from the patient, and up to 2 m spread on nearby surroundings.1 This macroscopic contamination is prevented when the aerosol box is employed.1

DISCLOSURES

Name: Mercedes Nicté López Hernández, MD.

Contribution: This author helped with the design of the box and recording of the video.

Name: Gerardo Esteban Álvarez Reséndiz, MD, MSc.

Contribution: This author helped with the design, script, and editing of the video.

Name: Yazmin Galván Talamantes, MD.

Contribution: This author helped with the design of the box and recording of the video.

Name: Juan Lagarda Cuevas, MD, MPH

Contribution: This author helped with the script of the video, manuscript preparation, and writing of the article.

Name: Eduardo A. Wilson-Manríquez, MD.

Contribution: This author helped design, edit, and record the video and proof read the article.

Name: Diana Stephanie Calva Ruiz, MD.

Contribution: This author helped design, edit, and record the video.

Name: Cristian Irvin Ham Armenta, MD.

Contribution: This author helped design, edit, and record the video.

This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.

    REFERENCE

    1. Canelli R, Connor C, Gonzalez M. Barrier enclosure during endotracheal intubation. N. Engl. J. Med. 2020; 382:1957–1958

    Supplemental Digital Content

    Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.