Rise and fall of the aerosol box; and what we must learn from the adoption of untested equipment.

How did an improvised medical device end up in widespread global use in May only to be left neglected in hospital offices 4 months later? In early 2020, anxiety escalated as the COVID-19 pandemic evolved. As SARS-CoV-2 infections and word of deaths of healthcare workers rippled through social media, clinicians at high risk of infection—those managing airways—began to look for ways to protect themselves. Concern about the adequacy of personal protective equipment was swiftly followed by the adoption of new equipment intended for staff safety. Transparent acrylic ‘aerosol boxes’ were novel protective devices intended to provide an additional layer of protection for clinicians from exposure to virus during the intubation of patients with COVID-19.1 The assumption was that any additional layer of protection would only add to the safety for the patients and clinical staff. However, there is increasing evidence to the contrary. With the publication of the study by Azhar et al , the evidence now strongly suggests that aerosol boxes increase intubation times, restrict movement and likely decrease first pass intubation success rate.2 A total of 36 post graduate emergency medicine trainees attempted videolaryngoscopy-assisted intubation of manikins in a simulated environment, while wearing standard PPE for aerosol generating procedures. The primary outcome measure was measurement of contamination of the room and PPE, but arguably the more important outcome measure is the risk to the patient from prolonged or repeated intubation attempts due to restriction of movement from the device. These findings compliment the first study published on these devices by …