Intubation Box design and collaboration is one of the great, emerging stories of the global fight against COVID-19. Companies all over the world are racing to produce these devices to help reduce Doctor and Nurse exposure to high viral concentrations during intubations.
Inexpensive, four-sided, plastic, partial-enclosures for endotracheal intubation seem to make a big safety difference. Various intubation box designs, when combined with cling-wrap or other draped covers, are in demand. Early research efforts in Boston and elsewhere are promising. As our medical friends tell us, the process of placing a breathing tube can be quite physical and involve large amounts of discharge from a coughing patient. These boxes can significantly restrict the radius of discharge.
As makers of semi-permanent and permanent PPE, we have been building a version of the intubation box. We want to share our observations with the community in the hopes that it helps advance the state of the art.
We suggest the use of PETG as readily available and affordable plastic for the intubation box design. Acrylic is a readily available, inexpensive plastic, but it is prone to shattering. Shattering is not an outcome you want for obvious reasons. Polycarbonate is strongly shatter-resistant. However, it is reportedly less amenable to cleaning. PETG has many of the shatter-resistant properties of Polycarbonate. Additionally, it has a much better affinity to cleaning with non-abrasive, low alkaline solutions. Given the rapid adoption of these non-certified boxes, it might also provide some comfort that PETG is a material already used in other sterile medical applications.
Packaging & Nesting:
Debate continues regarding flat-packing or shipping assembled. Flat-packing reduces shipping costs. However, it puts the burden on already stretched medical staff to construct and fully seal all the edges of the boxes. As anyone who has used super-glue before can attest, this is not always the easiest of activities. Shipping large, empty boxes assembled is expensive. We recommend slight variations to the base design that allow for nesting and shipping of three units per box. As hoped (through our very unscientific testing lying in the boxes), the roughly 1” difference in dimensions does not appear to reduce usability.
UPS or FedEx offering reduced-cost, expedited shipping would be helpful since overnighting can run $100 per package.
Some makers have suggested larger widths to accommodate larger US hospital beds and patients. Again, after some statistically insignificant research with some exhausted front-line doctors, we have decided to stick with variants based on a 21” wide standard. While US hospital beds may accommodate wider boxes, it seems that temporary hospitals and overflow rooms use narrower beds. Above all, slim boxes sit firmly on the bed and reduce demands on additional staff who would otherwise need to stabilize the device. We also see no evidence that the ~21” size significantly reduces fit since the box is meant to cover the head to the chin and is open around the neck.
There is still some debate on this feature in intubation box design, but we have chosen to utilize a slightly angled top piece to help improve visibility. For instance, brightly lit surgical rooms can create many reflections. PETG is shiny and angling can reduce this effect. It does come with the tradeoff of additional shipping size and cost, but that seems marginal when compared to the improved functionality.
Bevel the edges of the ports. It reduces the potential for a breach of the clinician’s worn PPE.
Cling Film or Ponchos? Ponchos:
An interesting intubation box design idea from the front lines and the team at Thalia (see their YouTube video) is to use cling film to help constrict air and fluid flow through the arm ports. By covering the box with the thin plastic wrap around the top third of the box, including the arm ports, you create a semi-sealed ring around the inserted arms of the clinician. You also may gain some additional restriction of aerosolization from the added barrier near the patient’s chin.
Some doctors told us that the loss of visibility from the sides is detrimental. They are indicating that they will continue to use thicker, impermeable arm coverings to “stuff” the holes. For example, they may continue to use ponchos. This has the effect of stuffing the port and providing a reasonable constriction of flow. It leaves a clear line of sight for other attending clinicians who might have to assess the patient or assist.
Thank you to our front-line doctors and nurses, many of whom have been intubating with the protection of ponchos and plastic bags. You are helping us with better intubation box design. American manufacturing is working on getting you what you need. Please comment below and keep the good ideas flowing.