• Anaesthesia · Apr 2020

    Review

    Personal protective equipment during the COVID-19 pandemic - a narrative review.

    Why do we need another PPE review?

    This review contextualises the PPE issues with their (relatively low quality) evidence base, focusing particularly on anaesthesia given that this is a high-risk occupational group. Coming from both a UK expert and journal, the recommendations should be carefully considered in terms of the UK's severe COVID outbreak and PPE supply issues.

    Important takeaways?

    • The significance of airborne transmission, in particular the infectivity of airborne viral particles beyond 1 meter, is uncertain.
    • PPE should be seen as an important and essential part of a larger safety system.
    • Intubation is a high-risk procedure for aerosol generation. A ventilated negative pressure room and airborne-precaution PPE is recommended. Ventilation (frequency of air-exchange) is likely more important than negative pressure.1 Chinese evidence suggests COVID transmission at intubation is low with appropriate PPE, although there is wide variability in extremes of PPE used along with post-exposure disinfection (eg. showering).
    • High-flow nasal oxygen and supraglottic airway (eg. LMA) placement may also be aerosol generating.
    • Most risk of transmission from sneezing and coughing is probably droplet and contact, rather than airborne, although the science behind these questions are complex and uncertain. Evidence attempting to answer these questions is often from non-clinical settings.
    • Fluid-resistant surgical masks when worn by staff may reduce transmission by at least 80%. Superiority of respirator masks (eg. P2,P3,N95) is not yet reliably supported by evidence.
    • Cook highlights two main PPE problems: 1. PPE supply; 2. Inappropriate use of PPE (using higher level than required).
    • PPE should be simple to remove (doff) after use, to reduce contamination risk. Cook notes that Canada's SARS experience highlighted increased risk of self contamination with more complex PPE.

    On specific levels of PPE

    • Contact precautions (gloves & gown) are recommended when in vicinity of COVID positive patient but not within 2 meters.
    • Droplet precautions (+ mask & eye protecting) are recommended within 2 meters of patients.
    • Airborne precautions (+ FFP3 respirator mask) are only recommended for aerosol generating procedures (AGP). However classification of procedures as AGP or not is only loosely evidence based.

    "Public Health England recommends airborne precautions are used in ‘hot spots’ where aerosol generating procedure are regularly performed, if any suspected COVID-19 patients are present – these include intensive care unit, operating theatre, emergency department resuscitation bays and labour wards where mothers are in stage 2 or 3 of labour"

    (Interesting that two recent meta-analyses found no evidence of benefit of N95 masks vs surgical masks for healthcare workers: Bartoszko 2020 & Long 2020.)

    Hang on...

    The elephant in the room is that the lack of PPE supply appears to be the main driver of the rapidly-changing PPE recommendations.

    PPE choices need to be made in consideration of the spectrum of risk, hazard and cost, acknowledging different risk profiles depending on location, procedure and individual clinicians.


    1. It's worth highlighting that negative pressure confers no protection on those in the room, it's purpose is to prevent escape of contagion to areas outside the room. 

    summary
    • T M Cook.
    • Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital NHS Trust, Bath, UK.
    • Anaesthesia. 2020 Apr 4.

    AbstractPersonal protective equipment has become an important and emotive subject during the current coronavirus disease 2019 epidemic. Coronavirus disease 2019 is predominantly caused by contact or droplet transmission attributed to relatively large respiratory particles which are subject to gravitational forces and travel only approximately 1 metre from the patient. Airborne transmission may occur if patient respiratory activity or medical procedures generate respiratory aerosols. These aerosols contain particles that may travel much longer distances and remain airborne longer, but their infective potential is uncertain. Contact, droplet and airborne transmission are each relevant during airway manoeuvres in infected patients, particularly during tracheal intubation. Personal protective equipment is an important component, but only one part, of a system protecting staff and other patients from coronavirus disease 2019 cross-infection. Appropriate use significantly reduces risk of viral transmission. Personal protective equipment should logically be matched to the potential mode of viral transmission occurring during patient care - contact, droplet or airborne. Recommendations from international organisations are broadly consistent, but equipment use is not. Only airborne precautions include a fitted high-filtration mask, and this should be reserved for aerosol generating procedures. Uncertainty remains around certain details of personal protective equipment including use of hoods, mask type and the potential for re-use of equipment.© 2020 Association of Anaesthetists.

      Pubmed     Full text   Copy Citation  

      Add institutional full text...

    This article appears in the collection: Anaesthesiology, Personal Protective Equipment (PPE) and COVID.

    Notes

    comment
    1

    Acknowledging the difficulty of balancing PPE supply and demand, the tone of this review tends to be biased toward hopeful but unproven assumptions that airborne transmission is not significant. There is considerable concern that this is in fact not true.

    When infection of a potentially fatal disease is occurring among frontline healthcare workers, a more cautious posture is warranted, along with greater acknowledgement of the uncertainty inherent in these recommendations.

    Daniel Jolley  Daniel Jolley
    summary
    1

    Why do we need another PPE review?

    This review contextualises the PPE issues with their (relatively low quality) evidence base, focusing particularly on anaesthesia given that this is a high-risk occupational group. Coming from both a UK expert and journal, the recommendations should be carefully considered in terms of the UK's severe COVID outbreak and PPE supply issues.

    Important takeaways?

    • The significance of airborne transmission, in particular the infectivity of airborne viral particles beyond 1 meter, is uncertain.
    • PPE should be seen as an important and essential part of a larger safety system.
    • Intubation is a high-risk procedure for aerosol generation. A ventilated negative pressure room and airborne-precaution PPE is recommended. Ventilation (frequency of air-exchange) is likely more important than negative pressure.1 Chinese evidence suggests COVID transmission at intubation is low with appropriate PPE, although there is wide variability in extremes of PPE used along with post-exposure disinfection (eg. showering).
    • High-flow nasal oxygen and supraglottic airway (eg. LMA) placement may also be aerosol generating.
    • Most risk of transmission from sneezing and coughing is probably droplet and contact, rather than airborne, although the science behind these questions are complex and uncertain. Evidence attempting to answer these questions is often from non-clinical settings.
    • Fluid-resistant surgical masks when worn by staff may reduce transmission by at least 80%. Superiority of respirator masks (eg. P2,P3,N95) is not yet reliably supported by evidence.
    • Cook highlights two main PPE problems: 1. PPE supply; 2. Inappropriate use of PPE (using higher level than required).
    • PPE should be simple to remove (doff) after use, to reduce contamination risk. Cook notes that Canada's SARS experience highlighted increased risk of self contamination with more complex PPE.

    On specific levels of PPE

    • Contact precautions (gloves & gown) are recommended when in vicinity of COVID positive patient but not within 2 meters.
    • Droplet precautions (+ mask & eye protecting) are recommended within 2 meters of patients.
    • Airborne precautions (+ FFP3 respirator mask) are only recommended for aerosol generating procedures (AGP). However classification of procedures as AGP or not is only loosely evidence based.

    "Public Health England recommends airborne precautions are used in ‘hot spots’ where aerosol generating procedure are regularly performed, if any suspected COVID-19 patients are present – these include intensive care unit, operating theatre, emergency department resuscitation bays and labour wards where mothers are in stage 2 or 3 of labour"

    (Interesting that two recent meta-analyses found no evidence of benefit of N95 masks vs surgical masks for healthcare workers: Bartoszko 2020 & Long 2020.)

    Hang on...

    The elephant in the room is that the lack of PPE supply appears to be the main driver of the rapidly-changing PPE recommendations.

    PPE choices need to be made in consideration of the spectrum of risk, hazard and cost, acknowledging different risk profiles depending on location, procedure and individual clinicians.


    1. It's worth highlighting that negative pressure confers no protection on those in the room, it's purpose is to prevent escape of contagion to areas outside the room. 

    Daniel Jolley  Daniel Jolley
    comment
    0

    Some of the assertions in this review are challengable, and based upon sources with lesser certainty than suggested. For example:

    "COVID-19 is predominantly caused by contact or droplet transmission..." - Cook

    Yet the reference for this is a Public Health England statement describing this as an 'assumption' without evidence. In contrast there is now considerable debate as to the significance of airborne COVID-19 transmission.

    "The transmission of COVID-19 is thought to occur mainly through respiratory droplets generated by coughing and sneezing, and through contact with contaminated surfaces. The predominant modes of transmission are assumed to be droplet and contact." – Public Health England

    Because PPE recommendations are based upon this assumption, caution is still required.

    Daniel Jolley  Daniel Jolley

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