Protecting Health Care Workers: Use of a Body Covering Transparent Sheet During and After Intubation of Patients With COVID-19.

To the Editor

Health care workers are at high risk of being infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), and some even die from coronavirus disease 2019 (COVID-19).[1] Oral droplets of liquid resulting from speech or coughing can pose a serious risk to medical personnel, especially when a patient with COVID-19 needs intubation.[2,3] Because standard protective equipment may not always be available or may not provide adequate protection (eg, a shifted and displaced facemask), physicians are looking for additional, easy-to-use protective barriers. Recently, Lai and Chang[4] suggested using a cardboard box during intubation to reduce the risk of transmission to caregivers. In our opinion, the idea is very good;however, such a device is probably of limited feasibility in clinical routine, as it limits the view of patients and caregivers. In addition, the box is likely to be an obstacle when the intubation is unexpectedly difficult with all devices stuck in the side ports of the shield. Therefore, we suggest a useful alternative to further reduce the risk of staff infection during airway management.

A simple tool is a transparent plastic sheet (TS), which is often used to cover clean hospital beds (Figure, panel B). We use this barrier in addition to protective masks, gloves, goggles, and clothing during the intubation process. After a detailed explanation of the measures to be taken, the patients agree to the spread of the TS over the entire body including the head. The TS should be handled with care and in slow motion to avoid air turbulences and holes. The patient, who is monitored with pulse oximetry, electrocardiogram (ECG) and invasive or noninvasive arterial blood pressure measurements, can breathe freely through an oxygen mask, communicate, and observe the surroundings underneath the TS before intubation. Furthermore, the cover fits everyone irrespective of the patient’s body mass index (BMI).

Handling of a body covering TS. A, Intubation underneath a TS (a handle can be used to lift the cover up from the patient's face); B, subsequent short distance transport within the hospital. Demonstration with a simulated patient. TS indicates transparent plastic sheet.

The intubation itself takes place under the TS using video laryngoscopy with a monitor outside the TS (Figure, panelA).[5] Alternatively, a handle can be used to lift the cover off the patient’s face during airway management (Figure, panelA). Compared to an aerosol box specially developed for intubation,[3] a TS also offers a good view of the patient’s head and oral cavity, additionally to this, it is very easy to handle if the intubation is unexpectedly difficult. The TS provides extra protection against possible air turbulences due to accidental leakage or disconnection of the breathing tubes, unplanned manual ventilation via facemask, or other unforeseen events. After the intubation, this effect can also be helpful during transport within the hospital to the intensive care unit (Figure, panelB).

In our experience with 60 patients suffering from severe acute respiratory failure due to COVID-19, TS can be recommended in addition to standard protective equipment during intubation and subsequent short distance transport within the hospital. The use of a TS is demonstrated in a tutorial video on intubation of patients with COVID-19.[5] We would like to share this inexpensive and convenient additional protection with our colleagues around the world to increase safety of health care workers.[6]