key: cord-0786438-4ggmvy0p authors: Wee, Jing Zhong; Lim, Vera; See, Jee Jian title: Utility of a barrier enclosure in the management of a patient with coronavirus disease for endoscopic retrograde cholangiopancreatography under sedation date: 2020-07-21 journal: Korean J Anesthesiol DOI: 10.4097/kja.20298 sha: 1f9a00bac24c193046ec5ebcec17919b8846add2 doc_id: 786438 cord_uid: 4ggmvy0p nan ly at the start of the procedure. Droplet infectivity is multifactorial, depending on the droplet size, number, velocity, and viral load [3] . It is thought that ranges of droplet size and number are produced in a single coughing event. The smaller the size, the longer they remain suspended in the air. As large droplets dry, it is unknown if smaller aerosols are produced. Some aerosols are produced with normal breathing, while coughing produces aerosols profusely. The box may trap secretions and large respiratory droplets during the passage of the endoscope, suctioning, or patient coughing. Further, this may decrease the virus burden reaching the healthcare worker. In a simulation by Canelli et al. [4] , the use of a barrier enclosure for intubation contained fluorescent dye within the inner surfaces of the enclosure, suggesting reduced macroscopic contamination of the immediate surroundings. The effect of barrier devices on airborne particles, however, may be less benign. Simpson demonstrated that airborne transmission to the healthcare worker increased substantially when using an aerosol containment device [5] . Additionally, since the virus may remain viable in aerosols for 3 h [6] , infectious aerosols can be released on box removal. Hence, the barrier should only be removed when the risk for aerosolization is deemed to be low and performed in a controlled manner to minimize the dispersal of viral particles. The opening in the box held the endoscope in place after optimal positioning; however, with fixed openings, access to the patient for suctioning and repositioning was restricted. When the patient started moving excessively, an assistant reached the patient via the openings opposite the endoscopist while sedation was titrated. The openings allowed the anesthetist and assistant to intervene, but for patients with a high risk for deterioration, require-ment of emergent intubation, or morbid obesity, the box may impede a quick access. The procedure was completed in 1 h with the pigment stone removed and biliary stent inserted. The patient remained stable throughout. He was asked to turn to the supine position in the box, and a surgical mask was applied. The processes of box removal and decontamination were performed with much care to avoid contaminating the surroundings with droplets remaining on the inner surface of the box or the patient's blanket or bed. The half-life of the virus on plastic is 6.5 h [6] ; therefore, careful removal of the box and meticulous decontamination are imperative. It required considerable effort with numerous wipes used to ensure that every crevice was clean. A liquid or vapor disinfectant could serve as a more convenient decontamination method. 1) The postoperative course was uneventful, and the patient was transferred back to the general ward. The barrier enclosure is an alternative physical barrier to large droplets or splatters during endoscopy, particularly if PPE is not available. However, the user must be mindful of the limitations that come with its use, including a potential for increased airborne particle exposure, if not properly utilized. Intubation boxes for managing the airway in patients with COVID-19 Aerosols, Droplets, and Airborne Spread: Everything you could possibly want to know Barrier enclosure during endotracheal intubation Measurement of airborne particle exposure during simulated tracheal intubation using various proposed aerosol containment devices during the COVID-19 pandemic Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1 Jin Long Chong for gifting us with the barrier enclosure box and Christopher Chia, endoscopist, for the procedure. No potential conflict of interest relevant to this article was reported.