Opening the discussion on a closed intubation box

BACKGROUND: Airway management for patients with COVID-19 poses a significant infection risk to clinicians. As such, some providers have adopted the "COVID intubation box", a cuboid barrier which which separates the clinician from the airway. While this device has limitations, there is promising evidence on its effectiveness. AIM: To summarize the history, evidence, and limitations of the popular intubation box design. Furthermore, we share our modified design and experiences from airway simulations. METHODS: Using our prototyping and validation facilities, our team designed and iteratively improved our device to arrive at a final design. The expert panel, consisting of anesthesiologists, infection control staff, and emergency clinicians, trialed the device using airway simulation mannequins and provided feedback. RESULTS: Our final device features a dome shape, increased height, wider arm port diameter, additional side port for assistants, and drapes to reduce viral escape. Feedback from simulations was overall positive, especially noting that the height and arm port diameter facilitated arm motion within the box. The infection control team preferred the unique dome shape for safe disinfection. CONCLUSION: Our intubation box overcomes several challenges and criticisms of the popular intubation box. This device is an important harm reduction tool for clinicians during this COVID-19 pandemic.