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Table of Contents
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 150-152

COVID aerosol barrier intubation box – Boon or bane?

1 Department of Anaesthesia and Critical Care, Level III UN Hospital, Goma, Democratic Republic of the Congo
2 Department of Anaesthesia, Madhukar Rainbow Children's Hospital, Delhi, India
3 Department of Anaesthesia, Ojas Hospital, Panchkula, Haryana, India
4 Department of Obs and Gyn, Level III UN Hospital, Goma, Democratic Republic of the Congo
5 Department of Psychiatry, Level III UN Hospital, Goma, Democratic Republic of the Congo

Date of Submission24-May-2020
Date of Acceptance19-Jun-2020
Date of Web Publication31-Jul-2020

Correspondence Address:
Dr. Shibu Sasidharan
Head, Department of Anaesthesia and Critical Care, Level III UN Hospital, Goma
Democratic Republic of the Congo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacp.JOACP_290_20

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How to cite this article:
Sasidharan S, Goyal R, Babitha M, Singh S, Dhillon HS. COVID aerosol barrier intubation box – Boon or bane?. J Anaesthesiol Clin Pharmacol 2020;36, Suppl S1:150-2

How to cite this URL:
Sasidharan S, Goyal R, Babitha M, Singh S, Dhillon HS. COVID aerosol barrier intubation box – Boon or bane?. J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2021 May 18];36, Suppl S1:150-2. Available from:

The reports of health care workers (HCW) getting infected with Corona Virus in this COVID-19 pandemic are disheartening. Extensive studies and reports have found that the greatest risk of infection is during aerosol generating procedures such as intubation, bronchoscopy etc.[1] With the growing number of cases, and increased infection of HCWs, the need for personal protective equipment (PPE) takes prominence more than ever before. The misfortune of non-availability of PPE has led to innovations like barrier protection from aerosols, using the Aerosol Box.[Figure 1][2] The original aerosol box was created by Dr. Hsien Yung Lai in Taiwan. Literature is replete with evidence that the aerosol box is effective in preventing cough dispersion of infective particles on the care providers.[3]
Figure 1: COVID aerosol barrier box

Click here to view

However, in our experience, things were different; the benefits of the 'box' were far less than the demerits. We encountered some challenges at our institution over the last two months, both during patient care (10 patients) and during simulation (5 attempts on mannequins) that we would like to share. The following were our observations:

  1. User discomfort is a major disqualifier. Both the laryngoscopist and the assistant were finding it difficult to adjust to the limited space available. The laryngoscopist gets very little space to manoeuvre his arms through the entry space for the arms and the assistant feels cramped inside the box
  2. There were additional issues in some of the patients. Manoeuvrability inside the aerosol box becomes further compromised in patients with short neck making intubation even more challenging. Patients who are short statured need to be distanced away with respect to the laryngoscopist and it adds to the effort. Airway management and intubation is nearly impossible through the aerosol box in those obese patients who require a steep ramping
  3. Not only is the box bulky, it adds another contaminated object after an aerosol dispersing procedure, which requires decontamination before reuse
  4. We used C-Mac® and AirTraq® in our patients and mannequins. Time taken for intubation through the box was much higher than usual. On an average, it took a trained anesthesiologist 121 seconds to intubate a patient through the box (defined as the time from removing the facemask until the 1st breath was delivered by a correctly placed endotracheal tube with an inflated cuff). This is much more than the routine time taken for intubation (Mean (SD); 14 (6) seconds for intubation with C-MAC® as compared to 22 (14) seconds with the AirTraq® in a difficult airway scenario in a mannequin[4]). This amount of time delay could be disastrous in a critically ill patient
  5. The box redirects the aerosols to the foot end of the patient through its distal open end, and thus the surface area with contamination on the patient linen/drapes still remains high.

Some investigators have also reported damage to the PPEs of the laryngoscopists due to the rough edges of the openings on the box. This exposed their clothes and/or skin to the virus.[5]

Due to the above observations, we strongly feel that the need of the hour is good PPE, donned properly as per guidelines and not the aerosol box. The amount of aerosol dispersion in a fully paralysed patient is minimal compared to a patient who is not.[6] Hence the benefit of the box in the presence of a PPE is weak. Stability of SARS-CoV-2 in different environmental conditions can be diverse. It is known to remain alive on paper, plastic and clothes for as long as 6 hours.[7] So it is imperative to doff the PPE and discard it, as per guidelines.

To summarise:

  • PPE is indisputably the main barrier to protect the HCWs from aerosol and the box should not be used as a replacement
  • The aerosol box should especially be removed whenever the patient safety seems compromised and an immediate intubation is required
  • Whenever the box is removed after use, appropriate decontamination has to be ensured
  • Most importantly, one should not rely solely on a box, for it cannot guarantee complete safety. It was an admirable innovation at the beginning of this pandemic but the authors would like to emphasise on good quality PPE over this method of contagion prevention.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Fowler RA, Guest CB, Lapinsky SE, Sibbald WJ, Louie M, Tang P, et al. Transmission of severe acute respiratory syndrome during intubation and mechanical ventilation. Am J Respir Crit Care Med 2004;169:1198-202.  Back to cited text no. 1
Girgis AM, Aziz MN, Gopesh TC, Friend J, Grant AM, Sandudrae JA, et al. Novel coronavirus disease 2019 (COVID-19) aerosolization box: Design modifications for patient safety." J Cardiothorac Vasc Anesth 2020;34:2274-6.  Back to cited text no. 2
Canelli R, Connor CW, Gonzalez M. Barrier enclosure during endotracheal intubation. N Engl J Med 2020. doi: 10.1056/NEJMc2007589.  Back to cited text no. 3
McElwain J, Malik MA, Harte BH, Flynn NM, Laffey JG. Comparison of the C-MAC videolaryngoscope with the Macintosh, Glidescope, and Airtraq laryngoscopes in easy and difficult laryngoscopy scenarios in manikins. Anaesthesia 2010;65:483-9.  Back to cited text no. 4
Begley JL, Lavery KE, Nickson CP, Brewster DJ. The aerosol box for intubation in COVID-19 patients: An in-situ simulation crossover study. Anaesthesia 2020. doi: 10.1111/anae.15115.  Back to cited text no. 5
Brewster DJ, Chrimes N, Do TB, Fraser K, Groombridge CJ, Higgs A, et al. Consensus statement: Safe airway society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. Med J Aust 2020;212:472-81.  Back to cited text no. 6
Chin AWH, Chu JTS, Perera MRA, Hui KPY, Yen H-L, Chan MCW, et al. Stability of SARS-CoV-2 in different environmental conditions. medRxiv 2020. doi:  Back to cited text no. 7


  [Figure 1]

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