LAUSR

Endoscopists with inadequate access to standard personal protective equipment (PPE) are being exposed to droplets from patients, some of whom may be positive for COVID-19, during upper endoscopy. Herein, we describe how a ready-made mouthpiece with a barrier (Valsa-mouth [Fig. 1A]; Sumitomo Bakelite Co, Ltd, Shinagawa-ku, Japan) may help protect endoscopists during endoscopic procedures. The mouthpiece was designed for the Valsalva maneuver, a forceful attempted exhalation against a closed airway to allow observation of the hypopharynx. The mouthpiece consists of a small hole through which an endoscope is attached and is able to close the patient’s airways with the exception of the nose. In our simulation (Video 1, available online at www. VideoGIE.org) an endoscopist in standard PPE took position to the left side of a cardiopulmonary resuscitation mannequin (Little Anne [Fig. 1B]; Laerdal Medical, Stavanger, Norway). To approximate a forceful cough and generate a spread of droplets and aerosols, water with fluorescent and soluble dye was sprayed from the oral cavity of the mannequin through the mouth and nose with atomizer (Fig. 1D).