Modified Protective Suits for Anesthesiologists Performing Tracheal Intubation for Severe Acute Respiratory Syndrome Patients in Taiwan

To the Editor:—Severe acute respiratory syndrome  (SARS) is a disease associated with coronavirus that has been recently described in patients in Asia, North America, and Europe. 1–3The outbreak of SARS occurred in northern Taiwan since March 2003 and spread all over the island in the following 2 months. Here we report our experience of using modified personal protective suits during tracheal intubation procedures in 40 patients who contracted SARS.

Since April 2003, there were 70 probable and suspected SARS patients in our medical center, which is a 2,400-bed tertiary hospital. The SARS patients were kept in negatively pressurized isolation units for intensive care. Among them, 14 patients eventually died because of intractable respiratory failure. All criteria for the diagnosis of probable and suspect SARS cases were based on the guidelines made by the World Health Organization. During the outbreak, 40 probable SARS patients were intubated by 8 anesthesiologists and 23 nurse anesthetists. Our practice guideline for tracheal intubation in SARS patients was similar to those mentioned by others. 4Because the personal protective equipment recommended by the Centers for Disease Control and Prevention, such as Stryker T4 (Stryker Instruments, Kalama-zoo, MI) and powered air-purifying respirators (e.g. , 3M AirMate; 3M, St. Paul, MN) were not available during the outbreak, we had to modify our own protective suits and equipment against SARS. The safety and efficiency of our modified suits, however, had not yet been proven. Figure 1displays mode 1 (an N-95 mask [3M], goggles, protective suits [Tyvek; DuPont, Wilmington, DE], and gloves), mode 2 (a half face piece with P-100 filter; 3M), and mode 3 (a half face piece with P3-level filter; SR-100, Sundstrom; The SEA Group, Warriewood, NSW, Australia). On top of one of three modes, a protective hood (SR-64; The SEA Group) and a full face shield, which was made of a piece of plastic cloth and a transparency film, were used to cover the head, neck, and front chest (fig. 2, left and middle panels). We also adapted mode 3 by connecting a nonrebreathing oxygen mask with a reservoir bag to the P3 filter (fig. 2, right panel). With such a device, it provided pure oxygen from a portable oxygen cylinder with a flow rate greater than 10 l/min. When air might be drawn from outside the mask when minute ventilation exceeded airflow rate, the virus load of inhaled air should be diluted. With the modified protective suits, 8 anesthesiologists and 23 nurse anesthetists participated in intubating 40 patients during the SARS outbreak. None of our anesthesia staff members contracted SARS.

Case reports of SARS to the World Health Organization were updated on July 2, 2003, including 8,442 cumulative cases and 812 deaths. Surveillance indicates 76% of infections were acquired in a healthcare facility. In 10–20% of cases, the respiratory illness was severe enough to require intubation and mechanical ventilation. The fatality rate among persons with illness meeting the current World Health Organization case definition for probable and suspected cases of SARS was around 3.4%. In Taiwan, there were 674 probable cases and 84 deaths (including 2 internists and 5 nurses) up until July 2. In our medical center, 14 of 70 SARS patients died (including 1 internist). Sixteen healthcare workers were infected, and 13 of them had participated in tracheal intubation procedures on three SARS patients. None of them had worn any protective suits during the intubation procedure and caused a high infectivity rate of SARS (100%, 13 of 13). Although standard precaution against droplets and contact has been shown effective for routine procedure, 4–5a higher level of personal protective equipment is recommended by the Centers for Disease Control and Prevention for high-risk procedures such as tracheal intubation. Because of the limited medical resources during the outbreak, powered air-purifying respirators and Stryker T4 protection systems were beyond our expectation. Using the modified protective suits during tracheal intubation procedures in 40 SARS patients (figs. 1 and 2), none of our anesthesia staff members contracted SARS (0%, 0 of 31). It should be noted, however, that not all of the commercially available protective equipment have been proven to be totally effective against coronavirus infection. Therefore, our limited experience on this suit modification should not be regarded as an accepted standard but only an alternative option when powered air-purifying respirators and Stryker systems are not available. Based on the Centers for Disease Control and Prevention recommendation and a recent editorial viewpoint, 4powered air-purifying respirators or Stryker T4 systems should be the minimum requirement when intubating SARS patients cannot be avoided.