Enhancing Safety of Clinicians Intubating COVID-19 Patients

Emergency medicine doctors and anesthesiologists at Brigham and Women’s Hospital have worked together to create lightweight hoods that provide a physical barrier between COVID-19 patients and clinicians during intubation. These homemade devices, each constructed with less than $20 worth of materials, offer an additional, urgently needed layer of protection when treating COVID-19 patients.

The intubation hood consists of a boxed frame that is made of polyvinyl chloride (PVC) tubing and elbows and is covered with a disposable plastic covering. Two large tegaderms are applied to the bag, and slits are cut so that the clinician can insert his or her hands. The hood is placed over the patient prior to intubation. Afterwards, it is lifted off the patient and put on the floor. The plastic covering is then gently removed and put in a biohazard bin, and the frame is cleaned in preparation for the next patient.

Fifteen of the hoods are now available for use at the Brigham, including in all of the hospital’s COVID units.

“The point of using these is to prevent those little aerosolized droplets that may be coming from the patient’s lungs before, during or even after intubation from spreading throughout the room,” said anesthesiologist David Preiss, MD, PhD, of the Department of Anesthesiology, Perioperative and Pain Medicine.

“Having a simple barrier keeps these droplets from getting on surrounding equipment, personnel, the floor and other surfaces you might touch later,” added Calvin A. Brown, III, MD, an attending physician in the Department of Emergency Medicine. “The hoods don’t replace the need for PPE, but they make our people feel a lot safer, especially given the number of COVID-19 patients we’re seeing every shift.”

Teaming up After Working in Parallel on Hoods

In the early stages of the COVID-19 outbreak, Dr. Brown and anesthesiologist Tara C. Carey, MD, were discussing intubation guidelines. Upon realizing that each department was also working on initial versions of an intubation hood, they decided to combine their efforts.

Members of both departments spent time workshopping ideas in the Brigham’s simulation center. Rather than a rigid plexiglass box, which some hospitals have used as a barrier device, they chose to use PVC, which is lighter. They also decided to incorporate a plastic covering into the apparatus as well as a hook on the back, which allows the box to stay in place while the patient is still awake and semi-upright when getting oxygenated for intubation.

“Collaboration between departments was key during this process,” Dr. Brown said. “Many departments are responsible for intubating COVID patients, so it’s important that everyone agrees upon a shared design. That way, if an anesthesiologist comes down to the ED to help us intubate a patient, they’ll know how to use our hood because it’s very similar, if not identical, to what they typically use.”

Creating a Negative-Pressure Environment

Ideally, patients would be intubated in a negative-pressure environment to minimize the spread of aerosolized droplets. An influx of COVID-19 patients and a lack of negative-pressure rooms, however, may make that impossible in many hospitals. If you are forced to intubate in a regular airflow room, a hood makes even more sense and would play a crucial role in keeping clinicians safe.

For the next version of the hood, Drs. Brown and Preiss hope to integrate suction to create negative pressure under the plastic drape. “That would be the optimal design, as negative pressure would help clear smaller airborne suspended viral particles,” Dr. Brown said.

The intubation hoods have been in use at the Brigham since April 10. A gastroenterologist and an interventional cardiologist in the Cardiac Catheterization Laboratory are among other Brigham specialists who have tried the hoods, which speaks to their adaptability.

“We wanted to create a device that could be used not only in the operating room, but also on the floors, in the ICU and potentially even with sedation cases, say in an offsite location where you don’t want aerosolization to occur,” said Douglas C. Shook, MD, chief of the Division of Cardiac Anesthesia. Dr. Shook, Dr. Carey and anesthesiologist Evan James Blaney, MD, were all major contributors to the development of the hood.

“One of the things that was really nice about this was the collaborative piece, where everyone was working toward a common goal,” Dr. Shook concluded. “That’s the part that made this project interesting and special, and it’s at the heart of who we are at the Brigham.”