Reducing the aerosol in flexible nasal endoscopy (FNE)/

Laryngoscopy(FOL) during Covid 19 ; a novel method

Arunachalam Iyer, Nick Calder, John Curran, May Yaneza.Department of Otolaryngology & Head neck surgery

University Hospital Monklands,Scotland, UK

Introduction

• Otolaryngology procedures are very risky during Covid pandemic• Flexible endoscopy (FNE/FOL) of upper airways can be an aerosol

generating procedure (AGP)• The FNE may need to be done in emergencies and Covid test is only

70% sensitive• The best strategy will be to reduce aerosol by barriers• Any barrier should • Provide air tight seal, easily available, cost effective, easy to use• Comfortable for the patient

Method & materials used

• Anaesthetic “closed” face masks; comes various sizes• Anaesthetic filter• DAR connecter which is L shaped with a closable hole for suction (

Covidien) • Alternatively instead of DAR connector, T –Piece connector 22m• Harness for attachment of CPAP masks ( VYGON)• If using T – piece then need to use a finger of a glove with a very small

hole for passing endoscope

Details of parts used

Closed face mask ( Large) DAR connector with suction port

Filter DAR connector lateral view

The assemblyThe kit attached to head with CPAP harness

Endoscopy on sim model T Piece attachment with glove finger

Endoscopy via t-piece Low pressure HME filter

Technical details

• The “Closed” anaesthetic masks comes in several sizes • Usually size 3&4 are suitable for women• Size 5 & 6 for men• The approximate size can be ascertained by measuring distance

between basal bridge & a point below the lower lip fully covering it• The mask might not fit in patients with a lot of facial hair, you can try

some gel on the face• For edentulous ones, leave the dentures in • Test the fit by asking to breath in & out after closing the filter; if fully

fit then it will be impossible do this• Use full PPE for AGP procedure

How to assemble the kit & proceed• Apply local anaesthetic in a cottonoid (NO SPRAY) to reduce cough /

sneeze• Note that the mask is used ”upside down” to keep opening in line with

nose! Use the camera and monitor as much as possible • Connect the mask with DAR connector • Attach the filter to the opening facing down• If using a T –piece instead, cut the little finger from a latex glove• Attach it tightly over the straight opening; make a very small opening with

a thick needle to pass the scope• Filter to the opening facing down; note • Attach the harness from behind the head of patient • Perform endoscopy• Remove the scope & mask & discard . The harness can be re-used after

cleaning with appropriate wipes for 60 seconds

Advantages & disadvantages

• Reduced chance of aerosol and contamination of clinic room• Utilizing already available equipment• Can be easily assembled• The CPAP harness can be re-used• Disadvantages• Slight discomfort to the patient• Can take more time to perform the procedure • Please watch video on simulation model

https://youtu.be/hPtUCOnCgak

Acknowledgements

• The NHSL Lanarkshire theatres staff for proving the necessary equipment

• The Simulation centre at University hospital Monklands

References

• 1) Workman AD, Welling DB, Carter BS, et al. Endonasal instrumentation and aerosolization risk in the era of COVID-19: simulation, literature review, and proposed mitigation strategies [published online ahead of print, 2020 Apr 3]. Int Forum Allergy Rhinol. 2020;10.1002/alr.22577. doi:10.1002/alr.22577

• 2)Using a facemask during anaesthesia Nicholas Boyd* and Anna Negus *Correspondence email: nicholasboyd@doctors.org.uk. Update in Anaesthesia | www.anaesthesiologists.org. https://www.wfsahq.org/components/com_virtual_library/media/82d2230d661107cb7de6e50247e3992a-987351810c49c9460d09aff4dc728ea3-Facemask-Anaesthesia--Update-27-2011-.pdf

• 2) Anaesthetic face masks - single use, Intersurgicalhttps://www.intersurgical.com/products/anaesthesia/economy-anaesthetic-face-masks