To the Editor:
The 2019 novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) and its associated disease, coronavirus disease 2019 (COVID-19), have resulted in a global pandemic and caused significant morbidity and mortality.1 The American Society of Echocardiography (Durham, North Carolina) released a statement adjudicating the use of personal protective equipment for all echocardiographic procedures. Special attention was given for transesophageal echocardiograms (TEE) which “carry a heightened risk of spread of the SARS-CoV-2 since they can provoke aerosolization of a large amount of virus.”2,3 The concern for potential aerosolization and provider contamination during the performance of TEE has led our institution to define all TEEs, even in the presence of an endotracheal tube managed airway, as an aerosol-generating procedure. This is in part because of the risk of small particle generation occurring during the procedure but also because of concerns over cross contamination of the probe, operator, echo machine, and surrounding surfaces with oropharyngeal secretions which are known to contain the virus.4 As such, full COVID-19 personal protective equipment consisting of an N95 respirator, face shield, gown, and two layers of gloves was mandated for all staff involved in the performance of TEE.
To reduce the risk of both aerosolization and provider/environmental contamination, we devised a sheathing system using two preexisting commercially available products seen in figure 1A. As demonstrated in figure 1B, a CIV-Flex 8.9 cm × 91.5 cm Transducer Cover (CIVCO, USA) probe cover is combined with a Blox 54 FR Endoscopic Bite Block (EndoChoice, Inc., USA) to create a freely sliding barrier which still allows the imager to position the TEE probe normally, then engage the bite block to the patient’s mouth and secure it around the head with the included elastic strap. Note that the distal end of the sheathing system is open to allow the probe to advance past the bite block with one of the included rubber bands holding the components together (fig. 1C) and the proximal extent of the sheath extending to the 1-meter mark (fig. 1D). The second rubber band is folded three times and secured around the proximal end of the sheath to keep it from moving. Step-by-step assembly instructions are demonstrated in Supplemental Digital Content, video 1 (http://links.lww.com/ALN/C390). This way, the combination of a secured airway via an endotracheal tube and a fully enclosed TEE sheath, we have converted our TEE procedure categorization from a high-risk aerosol-generating procedure to a low-risk procedure, removing the need for use of N95 masks. This simple and easily generalizable modification preserves scarce personal protective equipment resources5 and reduces the risk of contamination by the provider to oneself or the environment.
Although use of a TEE probe cover has been previously described,6 it does not eliminate contamination when the cover is moved within the oropharynx and the esophagus. The sheath design herein described maintains a noncontaminated surface for the echocardiographer to grasp when manipulating the TEE probe. In addition to mitigating the risk that SARS-CoV-2 poses to both patients and providers, we believe that this inexpensive adjustment to practice will reduce both unnecessary personal protective equipment usage and risk for contamination.
Support was provided solely from institutional and/or departmental sources.
Dr. Cawcutt was paid an honorarium for the creation of educational materials by the Society of Healthcare Epidemiology of America (Arlington, Virginia) and is a paid medical writer for The Clorox Company (Oakland, California). The other authors declare no competing interests.