Pediatric laryngoscopy and bronchoscopy during the COVID-19 pandemic: A four-center collaborative protocol to improve safety with perioperative management strategies and creation of a surgical tent with disposable drapes

Abstract

Aerosolization procedures during the COVID-19 pandemic place all operating room personnel at risk for exposure. We offer detailed perioperative management strategies and present a specific protocol designed to improve safety during pediatric laryngoscopy and bronchoscopy. Several methods of using disposable drapes for various procedures are described, with the goal of constructing a tent around the patient to decrease widespread contamination of dispersed droplets and generated aerosol. The concepts presented herein are translatable to future situations where aerosol generating procedures increase risk for any pathogenic exposure. This protocol is a collaborative effort based on knowledge gleaned from clinical and simulation experience from Children's Hospital Colorado, Children's Hospital of Philadelphia, The Hospital for Sick Children in Toronto, and Boston Children's Hospital.

Keywords: Aerosol generating procedures; Bronchoscopy; COVID-19; Coronavirus; Droplet; Laryngoscopy; Pediatric airway; Precaution; SARS CoV2; Suspension.

Fig. 1

Surgical tent for containing droplet and aerosolized particles during unsecured airway procedure. Three disposable drapes are used to prevent contamination, including 1) drape covering bed, 2) drape covering patient's body, 3) drape suspended over patient's head and chest to create contained working space or tent.

Fig. 2

Simulation of videolaryngoscopy under surgical tent. The mouth-to-mouth distance between patient and surgeon is increased compared to standard direct laryngoscopy while maintaining a clear field of view.

Fig. 3

Bronchoscopy tent with disposable drapes. A) Preoperative preparation involves impermeable blue sheet covering bed, bars ready at side of bed, large drape under which patient is placed. B) Simulation demonstrating bars in place to suspend drape over patient to create working space. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

Fig. 4

Simulation of surgical tent for suspension microlaryngoscopy and bronchoscopy created by attaching the microscope drape to the microscope lens and inverting the drape over the patient. The surgeon works through two slits for his or her hands.

Fig. 5

Confirmatory flexible bronchoscopy through a laryngeal mask airway with swivel connector and Tegaderm for suspected airway foreign body. The surgeon's arms are covered with video camera drapes and are placed through a Lap Ped-Neonatal Clear Drape that is suspended by a Mayo stand with tray removed and empty screw holes covered by Tegaderm adhesives. Equipment for rigid bronchoscopy is at the ready.

Fig. 6

Rigid bronchoscopy for foreign body removal. Surgical tent is constructed from an ether screen (cross bar) and an O-arm drape. The surgeon works through a small slit in the drape. There is a 1010 drape over the patient's chest and a smoke evacuator overtop to filter aerosolized product from under the tent.