Emergency Procedures in Isolated, Highly Contagious Patients
A randomized controlled study comparing advanced airway management in manikins while using Personal Protective Equipment, Portable Isolation Units and standard protection

Relevance of research: 
With rising incidence of Tuberculosis and Ebola, patient isolation and prevention of contagion continues to present challenges for healthcare providers. This study shows advanced airway management is possible despite patient isolation.
Background and Goal of Study: 
Contagion may be prevented using patient isolation units (PIU) or personal protective equipment (PPE). We investigated the effects of PIUs & PPE on time until ventilation (TUV) and subjective level of difficulty.
Materials and methods: 
With IRB approval, 20 anaesthetists, working in emergency services performed airway management on manikins in three settings: 1) manikin isolated in PIU, 2) participants wearing PPE, 3) standard setting. Six devices were used in each setting: Macintosh laryngoscope, Airtraq SPTM videolaryngoscope, i-gelTM, ILMA FastrachTM, Ambu® fibreoptic aScopeTM and Cook Melker cricothyrotomy Catheter SetTM. Order of settings and devices was randomized. We timed the tasks and asked participants to rate subjective levels of difficulty on a VAS-Score.
Results:
In 85% of attempts, regardless of setting or device, participants were able to secure the airway in under 60s. The time-until-ventilation was shorter than 60s in 94% of attempts in standard setting, 90% whilst wearing personal protective equipment and 73% whilst the manikin was isolated in the portable isolation unit. Taking each individual device into consideration, the time-until-ventilation differed significantly in each setting (p<0.01). In the standard setting mean time-until-ventilation was 31±26seconds (95%CI: 26-36seconds), although time varied considerably between the devices: from fastest (i-gel, 8±2seconds (95%CI: 7-9seconds)) to longest (Cricothyrotomy 62±20seconds (95%CI: 53-72seconds)). Longer times-until-ventilation were observed in the PIU-Setting: 65±63seconds (95%CI: 54-76seconds). In the PPE-Setting it was 35±30seconds (95%CI: 29-40seconds). The overall level of difficulty (VAS-Score) was significantly different between each setting (p<0.01). It was highest for the PIU (74±13) compared with standard-setting (9±7) and PPE-Setting (42±18).
Discussion and Conclusion(s):
Wearing personal protective equipment only slightly prolongs time until ventilation, when compared to the standard setting. However, handling of the protection equipment is difficult, and contamination possible. The PIU is a safe alternative, while it considerably affects medical tasks. Cricothyrotomy and the use of a fibreoptic scope within a PIU-Setting are very difficult and excluding it from the analysis increased success-rates for ventilation under 60s to 91%. This shows, that though challenging for healthcare professionals, airway management in a PIU setting is feasible within a clinically tolerable time frame. With overall average times until ventilation of around 10s, supraglottic airway devices remain highly recommendable tools, even in this challenging setting.

Is advanced airway management feasible in isolated patients? A comparison of personal protective equipment (PPE), Patient isolation Units (PIU) and standard protection measures, using manikins