Opening Pandora’s Box: Aerosol boxes and barrier enclosures for airway management in COVID-19 patients – a scoping review and narrative synthesis

Sorbello, Massimiliano; Rosenblatt, William; Hofmeyr, Ross; Greif, Robert; Urdaneta, Felipe

BACKGROUND: Exposure of healthcare providers to SARS-CoV-2 is a significant safety concern during COVID-19 pandemic, requiring contact/droplet/airborne precautions. Due to global shortages, limited availability of personal protective equipment has motivated the development of barrier-enclosure systems such as aerosol boxes, plastic drapes, and similar protective systems. We examined the available evidence and scientific publications about barrier-enclosure systems for airway management in suspected/confirmed COVID-19 patients. Medline/EMBASE/Google Scholar databases (December 1/2019 - May 27/2020) were searched for all articles on barrier enclosures for airway management in COVID-19, including references and websites. All sources were reviewed by a panel of experts using a Delphi method with a modified nominal-group technique. RESULTS: Fifty-two articles were reviewed for their results and level of evidence regarding barrier device feasibility, advantages, protection against droplets and aerosols, effectiveness, safety, ergonomics, and cleaning/disposal. The majority of analysed papers were expert opinion, small case-series, technical descriptions, small-sample simulation studies, and pre-print proofs. CONCLUSIONS: The use of barrier-enclosure devices adds to the complexity of airway procedures with potential adverse consequences, especially during airway emergencies. Concerns include limitations on the ability to perform airway interventions and the aid that can be delivered by an assistant, patient injuries, compromise of PPE integrity, lack of evidence for added protection of healthcare providers including secondary aerosolization upon barrier removal, and lack of cleaning standards. Enclosure barriers for airway management are no substitute for adequate PPE, and their use should be avoided until adequate validation studies can be reported.