The Airway Procedure Tent Background: from a Frontline Clinician

by Amy Keim, MS, PA-C | Associate Clinical Professor of Emergency Medicine | George Washington University School of Medicine and Health Sciences | George Washington University Medical Faculty Associates

When COVID-19, otherwise known as SARSCOV-2, struck the US, it was met with decades of emergency preparedness. The severe acute respiratory syndrome (SARS-COV-1) epidemic, as well as the Middle East respiratory syndrome (MERS-COV) had highlighted the challenges of managing a modern outbreak of a novel virus that easily crossed international boundaries and resulted in acute respiratory distress with high fatality rates. Despite what we learned, the enormous amount of research, advances in medical care, expertise that grew out of those experiences, and development of robust emergency management practices, SARS-COV-2 has presented new and unanticipated challenges that have blindsided our healthcare system. We are rapidly identifying new problems and innovating to overcome them.

This includes innovating to stop the spread of the virus. COVID-19 virus particles are spread through the respiratory tract by aerosolization. This aerosolization of the virus can occur when someone with the viral infection coughs, talks, or breaths. A nearby individual can contract the virus through their mouth, nose, or eyes. In the hospital setting, patients with novel airborne respiratory viruses like COVID-19 are managed using Airborne Precautions. This is a set of very specific precautions taken by the healthcare team to limit the spread of the virus to other patients and staff.

It includes placing a patient in a negative pressure room (air pulls from the room into a special filter system) and wearing a high level of personal protective equipment (PPE), including an N95 mask.

When a patient with suspected or confirmed COVID-19 is in severe respiratory distress or cardiopulmonary arrest, life-saving interventions are rapidly deployed by the healthcare team. These interventions include procedures such as CPR or endotracheal intubation, which significantly

increase aerosolization of infectious particles and put the healthcare team, and potentially other patients, at higher risk of contracting the virus. As such, healthcare workers take extensive precautions to limit aerosolization while balancing the emergent needs of the patient. Because patients can be infected with COVID-19 without symptoms, or their presenting condition may be an atypical presentation of COVID-19 (like a life-threatening heart rhythm cause by the virus’ effect on the heart), any patient requiring a procedure with increased aerosolization requires the same level of precautions.

The sudden influx of patients requiring this level of airborne precaution has overwhelmed hospitals. Negative pressure rooms are very limited as are the higher levels of PPE recommended with the increased level of exposure risk. Many hospitals started implementing readily available plastic drapes over the patients to try to decrease aerosolized particles during airway procedures. However, the drapes create significant challenges by interfering with visibility and the mechanics of the procedures themselves, while providing an unreliable barrier. To better prepare for the inevitable influx of respiratory distress patients with suspected or confirmed COVID-19, medical and nursing staff practice new protective protocols using simulated patient exercises. It was while participating in one of these training events, watching those plastic drapes, that reality hit hard.

How do we balance our safety with that of our patients? There has to be a better way.

The following day I contacted Nova Labs, who were already providing local hospitals with highquality 3D printed face shields. I had an idea, but I needed a skilled engineer and manufacturers. The idea was to design and produce a tent to decrease the spread of aerosolized particles, give the medical provider full visibility and range of movement, accommodate different types of airway approaches, and not interfere with chest compressions/defibrillation. It would have to be inexpensive to make, easily produced by volunteers, cleanable with available hospital disinfectants, and pack flat for distribution.

Clinicians who have contributed to this project through tent testing and design feedback include:

Claudia Ranniger, MD Assistant Professor of Emergency Medicine Director of Simulation George Washington University School of Medicine and Health Sciences George Washington University Medical Faculty Associates

Michelle Divito, MD Department of Emergency Medicine Walter Reed National Military Medical Center

David Yamane, MD Assistant Professor of Emergency Medicine Assistant Professor of Anesthesiology and Critical Care Medicine Chief, Critical Care Section George Washington University Medical Faculty Associates

James Phillips, MD Assistant Professor or Emergency Medicine Chief, Disaster and Operational Medicine Section George Washington University Medical Faculty Associates

Joshua Kessler, MD Department of Emergency Medicine Walter Reed National Military Medical Center

Shannon Stout, MD Department of Emergency Medicine Walter Reed National Military Medical Center