key: cord-0975845-mbwc1gmh
authors: Emami, Nader; Taner, Tristan; Ogundipe, Funmilola; Hawn, Vivian S; Rubin, Randi; Skae, Catherine C; Shiloh, Ariel L; Keene, Adam B
title: Drape to Prevent Disease Transmission During Endotracheal Intubation
date: 2020-07-03
journal: Am J Infect Control
DOI: 10.1016/j.ajic.2020.06.212
sha: e091e02028bf5cfdc4e684987b1caf67996323be
doc_id: 975845
cord_uid: mbwc1gmh

Endotracheal intubation poses high risk of transmission of SARS-CoV-2 and other respiratory pathogens. We designed and here describe a protective drape that we believe will greatly reduce this risk. Unlike the intubation box that has been described prior, it is portable, disposable, and does not restrict operator dexterity. We have used it extensively and successfully during the height of the COVID-19 outbreak.

Abstract Endotracheal intubation poses high risk of transmission of SARS-CoV-2 and other respiratory pathogens. We designed and here describe a protective drape that we believe will greatly reduce this risk. Unlike the intubation box that has been described prior, it is portable, disposable, and does not restrict operator dexterity. We have used it extensively and successfully during the height of the COVID-19 outbreak.

Based on data from similar viral outbreaks, endotracheal intubation is considered to be the highest risk procedure for transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 1,2 Various recommendations have been made to decrease transmission during intubation. The use of video laryngoscopy by an experienced provider is currently considered standard of care. 3 In addition, the use of a rigid protective intubation box has been proposed. 4 At Montefiore Medical Center in the Bronx, New York, we intubated 367patients with Corona Virus Disease of 2019 (COVID-19) during the month of April 2020. Our engineering department constructed multiple protective intubation boxes. Unfortunately, in practice at Montefiore, we found intubation boxes to be impractical. They are bulky and heavy, making it difficult to transport them quickly to the various areas throughout the hospital in which emergent intubations occur. In addition, the boxes may limit manual dexterity to such a degree as to make emergent intubations more difficult. Another concern is that the boxes may not protect additional personnel in the room from caudal spread of infectious organisms, which is common during endotracheal intubation. 5 Finally, they require meticulous disinfection after each use, a process which itself carries some risk of disease transmission. Because of these limitations, the use of intubation boxes was abandoned shortly after deployment in our hospitals.

In order to overcome these limitations, we designed and have put into regular practice a disposable protective intubation drape for emergent intubation of patients with known or suspected SARS-Co-V-2 infection. The potential utility of plastic sheeting to limit the spread of infectious organisms during extubation has recently been demonstrated. 6 The use of such sheeting has not been described for use in endotracheal intubation.

To our knowledge, ours is the first reported use of a clear plastic drape that has been specifically designed to prevent the spread of infectious organisims during endotracheal intubation. The drape consists of a six-foot wide by nine-foot long thin (2 mil.) clear plastic sheet. As per the template in Figure 1 , six parallel nine-inch long by two-inch wide pieces of tape were placed along the drape at regular intervals. Openings were then cut lengthwise through the center of the tape to create the hand insertion ports. When two personnel are used, the time to cut and assemble a single intubation drape is under five minutes (see Video 1) . The drape should be disposed after each use. In order to limit spread of infectious organisms during disposal, we recommend rolling the sheet under in a fashion that the surface remains in contact with the patient and not the providers. After rolling under, the sheet should be folded and disposed of in a medical waste container.

This drape is easily portable to any location. In addition, we have found that that the drape allows for good manual dexterity. We have used it extensively at Montefiore Medical Center during the COVID 19 crisis with various forms of video laryngoscopy (see Video 2) . The flexible property of the drape allows for the intubation of patients without limiting manual dexterity. The drape is potentially protective not only of the intubator but also of other providers in the room who are usually located caudal to the patient's head.

The use of the drape may be limited by reduction in operator visibility. In addition, use in emergent situations can be somewhat confusing to those who are not familiar with the drape. For this reason, we designed the openings in the drape to be symmetric so that there can be no confusion over the proper orientation of the drape in cranial-caudad orientation.

In terms of sheet thickness, we found that 2 mil provides a reasonable balance of visibility and durability, with thinner sheeting being less durable and thicker sheeting creating a greater loss in visibility. In addition, the 2 mil sheeting does not adhere to the patient's skin and provides a degree of "tenting" that permits adequate separation between patient and provider so that instruments may be manipulated under the sheet with ease.

Due to the overwhelming clinical burden imposed by COVID-19 in at our hosptials, we were unfortunately unable to collect data on comparative intubation success rate with and without the drape. In addition, we were not able to study whether the use of the drape actually reduced the rate of transmission from patient to provider during intubation. However, after initial experience with the drape the directors of all three emergency departments on the main Montefiore Medical Center campuses as well as the Division of Critical Care Medicine have requested distribution of the drape to all of their patient care areas. So far 900 drapes have been produced and distributed to these areas, with multiple requests to restock these drapes fulfilled.

We would like to share the design of this drape with all and hope to decrease the rate of patient to provider transmission of the SARS-Co-V-2 virus. We hope that future studies will be able to investigate both the effects of the use of the protective drape on first-pass intubation success as well as the degree to which the drape may be effective at preventing disease transmission in clinical practice. 

Transmission of Severe Acute Respiratory Syndrome during Intubation and Mechanical Ventilation

Risk Factors for SARS Transmission from Patients Requiring Intubation: A Multicentre Investigation in Toronto

Surviving Sepsis Campaign

Barrier Enclosure during Endotracheal Intubation

Exhaled air dispersion during bag-mask ventilation and sputum suctioning-Implications for infection control

Clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for COVID-19