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Brief Reports, Book & Media Reviews, Correspondence, Errata: Letter to the Editor

Preloading Head Supports to Avoid Anesthesia Circuit Disconnections During the COVID-19 Pandemic

Green, James S. MBBS, FRCA; Dillane, Derek MB BCh, FCARCSI

Author Information
doi: 10.1213/ANE.0000000000005128
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To the Editor

We read the recent articles by Brown et al,1 Lai et al,2 Tsai et al,3 and Endersby et al.4 describing barrier devices for reducing aerosol and droplet transmission in coronavirus disease 2019 (COVID-19) patients with interest. The COVID-19 pandemic has highlighted safety concerns for anesthesia, surgery, and nursing staff during aerosol-generating procedures including endotracheal intubation5 and the airway management landscape is rapidly evolving to reduce risk of transmission. Anesthetic ventilator tubing disconnection also poses a significant contamination risk to members of the operating room (OR), whether planned or unplanned and limiting the number of disconnections intuitively makes sense. We would like to bring to the attention of the reader how the simple practice of “preloading” the head positioning supports used for patients undergoing surgery in the prone or sitting positions eliminates the need for planned tubing disconnection.

The appropriate head positioning support can be preloaded over the ventilator tubing carefully ensuring that the orientation is correct (so that the support will fit over the patient's face as intended once the ventilator tubing is connected to the endotracheal tube) before induction of anesthesia (Figure). A rest on the anesthesia machine, the filter on the expiratory limb, or tape can be used to fix the facial side of the head support to the ventilator end of the circuit.

A, Gel Facemask (Smith and Nephew T-Max Beach Chair; T-Max Shoulder Positioner, Smith+Nephew; Resting directly on the anesthetic machine. B, ProneView Head Positioning System (Dupaco; ProneView Protective Helmet System, Dupaco; Resting on the filter attached to the expiratory limb.

Once endotracheal intubation has been achieved and the tube secured the support can be moved carefully over the ventilator tubing toward the patient to allow head positioning without circuit disconnection. Before emergence, the support can be moved over the ventilator tubing back to the position adjacent to the ventilator to allow access to the patients’ airway.

The authors have successfully used this technique to eliminate planned circuit disconnections on patients undergoing shoulder, spine, orthopedic trauma, and plastics/burns over the past month. Before adopting this preloading technique, 2 circuit disconnections were necessary for patients positioned prone or sitting for surgery; the first to apply the head support following endotracheal intubation and the second to remove the head support following surgery and before extubation. There is no associated cost with preloading the support, and in each case, the technique allowed an intact ventilatory circuit to be maintained throughout surgery from endotracheal intubation until extubation.

As elective surgeries resume following the COVID-19 lockdown and surgical volumes return to normal levels, anesthetists, surgeons, and nurses in the OR will continue to be exposed to the risk of transmission of COVID-19. All efforts should be made to reduce this risk and preloading the head support using the described method offers a simple and safer choice to standard practice as unnecessary circuit disconnections can easily be avoided. This technique should certainly be considered as airway management and ventilatory support continues to evolve with the goal of protecting the providers as well as the patients.

James S. Green, MBBS, FRCA
Derek Dillane, MB BCh, FCARCSI
Department of Anesthesiology and Pain Medicine
University of Alberta Hospital
Edmonton, Alberta, Canada


1. Brown S, Patrao F, Verma S, Lean A, Flack S, Polaner D. Barrier system for airway management of COVID-19 patients. Anesth Analg. 2020;131:e34–e35.
2. Lai Y, Chang C. A carton-made protective shield for suspicious/confirmed COVID-19 intubation and extubation during surgery. Anesth Analg. 2020;131:e31–e33.
3. Tsai P. Barrier shields: not just for intubations in today’s COVID-19 world? Anesth Analg. 2020;131:e44–e45.
4. Endersby RVW, Ho ECY, Spencer AO, Goldstein DH, Schubert E. Barrier devices for reducing aerosol and droplet transmission in COVID-19 patients: advantages, disadvantages, and alternative solutions. Anesth Analg. 2020;131:e121–e123.
5. El-Boghdadly K, Wong DJN, Owen R, et al. Risks to healthcare workers following tracheal intubation of patients with COVID-19: a prospective international multicentre cohort study. Anaesthesia. 2020 June 9 [Epub ahead of print].
Copyright © 2020 International Anesthesia Research Society