Balancing the Benefits, Risks of Aerosol Box use During Medical Procedures


Implementing an aerosol box during aerosol-generating medical procedures significantly reduces healthcare practitioner contamination, but also delays the time to successful intubation, which can negatively affect patient outcomes.

Balancing the Benefits, Risks of Aerosol Box use During Medical Procedures

Adam Cheng, MD

Credit: NYSIM

Using an aerosol box during aerosol-generating medical procedures (AGMPs) reduced contamination deposition on health care practitioners (HCPs) but delayed successful intubation, as demonstrated in recent research.

The study results emphasize the importance of balancing the benefits of these procedures, with the possible negative impacts. Reduced contamination for HCPs is important, but the potential negative impact on patient outcomes due to the delay in completing intubation also needs to be considered, the research noted.

An increase in AGMPs has been prompted by the COVID-19 pandemic, and with it came concerns about HCP exposure to the virus. The aerosol box has been introduced as a potential solution to minimize HCP exposure during these procedures.

Adam Cheng, MD, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, and a team of investigators, aimed to determine if implementing an aerosol box during AGMPs would decrease HCP contamination, or influence the time to successful completion and first-pass success rate for endotracheal intubation (ETI) and laryngeal mask airway (LMA) insertion.

In the multicenter, simulation-based, randomized clinical trial a total of 64 teams of 128 participants were enrolled in tertiary care in pediatric hospitals from May-December 2021.

The participant teams performed 3 simulated patient scenarios: bag-valve-mask ventilation, endotracheal intubation (ETI), and laryngeal mask airway (LMA) insertion.

During the scenarios, aerosols were generated using Glo Germ, a fluorescent powder that simulates the spread of respiratory secretions. Teams of 2 HCPs were randomized to either the control group without an aerosol box or the intervention group with an aerosol box.

The aerosol box used in the study was the SplashGuard CG, a transparent, plastic barrier covering the patient's head and shoulders with access ports allowing HCPs to manage the airway.

The primary outcome of the study was the surface area of contamination on participants, and the secondary outcomes were the time to successful completion and first-pass success rates for ETI and LMA insertion.

The results showed that the use of an aerosol box was associated with a 77.5% overall decreased area of contamination to the torso and a 60.7% overall decreased AOC to the facial area in airway HCPs.

No statistically significant difference was found in surface contamination after doffing personal protective equipment between the 2 groups.

The study also found that the time to complete ETI was longer in the aerosol box group compared with the control group, with a mean difference of 10.2 seconds. Though, there was no difference between the 2 groups for LMA insertion, with a mean difference of 2.4 seconds. These data suggest that the incremental benefits of reduced surface contamination from aerosol box use should be weighed against delayed time to complete intubation, which may negatively affect patient outcomes.


  1. Cheng A, Pirie J, Lin Y, et al. Aerosol Box Use in Reducing Health Care Worker Contamination During Airway Procedures (AIRWAY Study): A Simulation-Based Randomized Clinical Trial. JAMA Netw Open. 2023;6(4):e237894. doi:10.1001/jamanetworkopen.2023.7894
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