Intubation Box

The purpose of an intubation box is to contain as much as possible the spread of aerosolized droplets containing Covid-19 viral particles during endotracheal intubation. Based on recent discussions with Anesthesiologists, Intensivists and Surgeons, this is most often happening in regular hospital beds of patients who suddenly decompensate and need urgent intubation. It can also happen in the Emergency Department or Operating Room. This is important because the average OR table is 20" wide, which is too narrow for an effective box with seals around the hand ports. A workaround is to put both armboards on either side of the OR table. A regular hospital bed will allow a box 24" wide without modification.

The design I am offering represents the final iteration of many previous models and designs and I want to thank David Earle MD, Mark Puls MD, Michael Sarup MD, Mary Aaland MD, members of our Anesthesia staff, nursing staff, and my sister Kathy Alexander at J&R Glass who expedited the prototype and got it made in under 24 hrs.

Design considerations are as follows: The box needs to allow placement of the anesthetist's hands through a sealing port at the head of the table. It needs to allow a helper to hold an endotracheal tube or apply cricoid pressure from the right. This assumes that most intubators are right handed.  The seals are Applied Medical XL Wound Protectors. Approximate cost $35 each, three will be needed. The box must be easily cleaned.Cleaning instructions came with our box. NO BLEACH or PURE ETHANOL, they will cloud the polymer. It must be strong. The ideal choice is Polycarbonate (Lexan).  Acrylic is a poor second choice, it is weaker.  

Fabrication tips: It is stronger, cleaner (in looks and easier to clean) if you let a fabricator make this as an inverted "U" shape and then glue on the front and back panel.  This is designed to allow a 4'x8' panel as building stock, this way there will be less waste and the cost will be lower.  You can make them yourself, however it is hard to glue something this big and keep it true and square. Also your non-professional glue joints will tend to fall apart in rough service and they will not be easy to keep clean. The glued joints (as opposed to the heat-bent joints) should be reinforced with aluminium angle stock. It is a two person job to lift these and put over a patient. Ideally they should be cleaned after use and put on a cart ready for next use. Ideally you will have one everywhere where you will be intubating these patients. This is not something that is going to be carried from code to code all night long without danger of breakage. So you may need one for ICU, ER, and OR.

Reassure the patient that this is a temporary measure and someone will be there to get the tube out when they recover. Cover the patient's  side with a loose drape, sheet, or bath blanket to reduce the egress of viral particles in the forward direction.

 

Intubation Box with Applied XL Wound Protectors in place

These require some tape to position and a loosely tied Penrose drain tied around the center. An alternative that works well is to wrap the box with Saran wrap or commercial grade food wrap covering the holes and wrapping upwards onto the 8" strip in the front. Make a small cruciate incision in the center of each hand port and the operator can push and it will stretch. Replace after each cleaning and reuse with fresh wrap. The intubator must be wearing full protective gear. Applied reminds us this is an "off-label" use of their product. 

Seals

This intubation box  depends on Applied Medical Wound Protectors XL Size Product Number C8404 to get a fairly airtight seal around the intubator's and helper's hands. They must be wearing gowns and gloves. The large polymer rings of the device are placed on either side of the box through a 6" hole, and it is tied in the center with a 1/2" Penrose drain. I advise wrapping it several times and tying it loosely. These should be replaced after each use.  No advice is given about the ability to disinfect or sterilize these. Other suggestions are to tape emesis bags or even bread bags into the openings.

The cheapest commercial glove box gloves, for gloves only, that I found were around $800 per pair, which is not economically viable. Applied Medical  has assurred me that they have a good stock of these wound protectors  in the supply chain all over the country and they are made in the U.S.  Ethicon makes a similar product. Use whatever is available. The XL size fits best with a 6" hole, you may need to tape these to keep them centered. In a pinch you could also use their XXL size.

Remember you will need 1/2" Penrose x3 for each use.

This is the drawing which incorporates the most helpful features and is easy to fabricate and clean.

The seal will not be perfect. The goal is to reduce the viral load getting sprayed directly on staff. On a Mallampati 1 or 2 airway a skilled operator can get the tube in without assistance.  A videolaryngoscope should be used.  Keep all other personnel out of the room.  For a Mallampati 3 or 4 airway cricoid pressure may be needed as well as someone to hold the tube. This is where the side port comes in handy. Put the scope and endotracheal tube with stylet on the patient's chest.Both the intubator and the helper need to be wearing full PPE.

What does "Nominal" Mean?

Nominal means the rough approximation of the dimension, just as a "2x4" is actually 1.5" x 3.5".  You are not going to figure out all the dimensions exactly because there will be some losses when this is cut from a 4'x8' sheet, also heat bending, which forms a superior joint, will use up more or less material depending on the temperature and bend radius. Leave this to your glass fabricator. They really are artisans. Also, they will never let it out of the shop without carefully rounding over the edges. They will also reinforce the glue joints with aluminum angle stock. If this is heat bent on a press, then the inverted "U" shape will be approximately 24"wide x 72"long prior to bending. 

Kathy Alexander and John Bessette at J&R Glass in Fitchburg MA jandrglass.com

For information on fabrication in the Northeast you can email kalexander@jandrglass.com or call 800-698-0177. If you wish to fabricate your own or have it done locally you should be able to do so from the plans.

There are volunteers in some locals working on these and if you can access the box this way that is a viable first step. Many larger places will need more than one. for example: https://www.gofundme.com/f/intubation-boxes-for-covid19-providers or www.intubationbox.org

Additional Design Ideas- PVC Tubing Box

I have an additional design which I give credit to my son for helping out with, my original concept was expensive and difficult and his was cheap and easy. The basic premise is to contract a 2'x2'x2' box out of 3/4" PVC pipe tubing, which is available at Home Depot, Lowes, or your local building supply or plumbing shop. It can be built for around $20.  

This can be made of 1", 3/4", or 1/2" tubing. It can be glued with PVC cement or left loose for easy cleaning.

It requires 11x2 ft. section of tubing. These come precut. It also requires 6x side outlet elbow pieces.It also requires 2 x 90 degree fittings.You can see the sku from HD if you magnify the image.

Assembly

I left mine unglued. The press fit is fine for ordinary use. This way it can be taken apart and put in a cleaning solution in between uses. In one version I wrapped it with Polyethylene 6" wrap so this could be discarded. This comes on 1000 ft. rolls but putting it on is very tedious. You then cover the box with Polyethylene cling wrap from HD. This comes on large rolls and it is cheap. You basically copy the intubation box from the first part of this website only make it out of plastic wrap. Again, very tedious. For the hand ports you cut a cruciate incision (just like a colostomy) they will stretch quite a bit and keep a good seal when the operator puts their hands through it. It is light so tape or secure it to the table or bed.  This is a low cost low resource solution to this problem which anyone can make. You can make enough to leave one in the ER, OR, ICU, etc.It is quite light and easy to carry.  You need someone dedicated and well-trained to rewrap this after each use and to disinfect the tubings. Another way to use it is to drape a disposable 9'x12'  1.9mil polyethylene painter's dropcloth over this. The point is to contain a spray of virus-laden droplets which sometimes happens with intubation.

This is the final version. Thanks again to Riley Alexander for design help. This is also light enough to tote. This is the one complaint about the Polycarbonate box, it needs a cart to move it efficiently especially while carrying an emergency kit.

Disclaimer.

These plans are furnished for use on an emergency basis to prevent or reduce the chance of life-threatening viral dissemination to our highly valued anesthesia, nursing, ICU and ER staff.   You and your institution assume all risks for their use. You should get input from your Anesthesia/ICU/ER  colleagues so everyone is on-board with the rationale for using this, this is to protect them and the people around them.

Finally.....

Again thanks to Ryan Bessette owner of J&R Glass and foreman Dave Zirkle who fabricated this in 24 hrs. and donated the protoype which is being used at Mercy Hospital in Springfield MA. 

If you are going to make one of these it is best to get started because Polycarbonate sheets are literally flying out of the warehouse, just overnight everywhere I looked had large barriers erected to prevent cough/sneeze impacts on the staff enclosed within. 

Thanks to our brave and dedicated nurses, support staff, Anesthesiologists and CRNAs, Emergency Physicians, ICU Physicians, Surgeons and other front-line caregivers. 

     "Improvise, Adapt, Overcome"- USMC

     "No act of kindness, however small, is ever wasted"-Aesop

     "Not to act is to act"-Dietrich Bonhoffer

     "Cast the burden upon the Lord, and he shall sustain thee" Psalm 55