Created April 28, 2020, last updated about 8 hours ago.
Collection: 121, Score: 182, Trend score: 0, Read count: 182, Articles count: 16, Created: 2020-04-28 23:13:07 UTC. Updated: 2020-05-13 21:18:47 UTC.
This growing collection of articles focuses on the evidence and expert guidance relating to the use of personal protective equipment (PPE) and the SARS-CoV-2 / COVID pandemic, with specific focus on PPE use by anaesthesiologists and anaesthetists.
More articles can found found via the PPE topic index.
What we know:
- Hospitals are frequent sources of outbreaks, among both staff, patients and the wider community.
- The quality of PPE evidence is low. Most evidence must be contextualised in consideration of expert opinion, and of the similarities between SARS-CoV-2 and SARS (SARS-CoV-1), MERS and influenza.
- Droplet-vs-airborne spread is a conceptual simplification and not a simple dichotomy. It is best understood as a spectrum of transmission risk.
- Time-exposed may be a more important consideration, especially in indoor, poorly ventilated spaces.
- PPE supply is globally limited, and so a pragmatic approach must be taken to its use, considering individual risk scenarios.
- Training, simulation and fit testing are critical for effective use of PPE.
- There are specific steps in the PPE donning & doffing workflow that are frequently associated with breaches exposing HCWs to infection. These require extra attention.
- Beyond cost, increasingly complex PPE (eg. PAPR, hoods, intubation boxes etc.) also increase the opportunity for PPE failure and exposure if users have not had adequate training in their use, and some PPE has been demonstrated to make intubation more difficult.
- The superiority of N95/P2 respirator masks over standard surgical masks for personal protection is unclear and unproven.
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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.
- 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"
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.
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. ↩
Lockhart et al. provide a considered exploration of COVID-19 infection-control issues specific to anaesthesiologists, proposing an additional third category of personal protective equipment (PPE).
Give it to me in point form!
They propose three PPE types:
- Droplet & contact precaution PPE: surgical mask, gown, gloves.
- General airborne, droplet & contact PPE: addition of N95 respirator mask and eye protection.
- PPE for high-risk aerosol-generating medical procedures: addition of gown neck protection and double gloves.
Why should I take notice?
The Canadian view on PPE is tempered by both their current significant COVID burden, and their experience of the 2003 SARS pandemic which infected 257 Canadians, 20% of whom were healthcare workers. Much of our PPE evidence is based upon SARS. This article emphasises the importance of PPE for anaesthesiologists and their airway assistants.
On airborne spread?
Unfortunately much of what we did not know about respiratory spread and SARS in 2005 persists today:
Although this observation [about lack of knowledge of SARS infectious droplets] was made 15 years ago, basic questions regarding nosocomial spread during the SARS epidemic, and now the COVID-19 pandemic, have yet to be answered.
Absence of evidence however, should not imply evidence of absent airborne spread.
The role of airborne particles in the spread of COVID-19 remains unclear, although Lockhart notes the infamous case of Hong Kong's Amoy Gardens housing complex in the 2003 SARS outbreak, resulting in 187 cases – likely via airborne spread.
Endotrachial intubation has been shown in several studies to be a high-risk procedure for healthcare worker infection. Considering this the authors reccomend a third level of PPE, adding:
- AAMI level-2 gown, incluidng neck protection, noting that the neck is a high-risk area for contamination in simulation studies.
- Double gloves that overlap the sleeve, noting that the gown-glove interface is a common PPE failure site, and that Verbeek's 2020 Cochrane review concluded that there was less contamination vs single gloving (RR 0.36).
- Only allow presence of essential staff in room during AGP.
- Provide access to shower resources for staff after high-risk AGP.
- Do not ‘‘MacGyver’’ homemade combinations of PPE.
- Doffing is a high-risk critical moment, that should not be rushed, distractions should be minimised, and use a doffing supervisor. Pay attention when donning to ease later doffing.
- Masks should be the last item removed.
Lockhart emphasises that there is no ideal PPE, but by focusing on consistent protection at known high-risk interactions (ie. intubation) safety improvements can be made.summary
What's worth knowing?
Overall most studies of PPE efficacy are of low quality and offer a low certainty of conclusions. Caveat emptor...
- Powered air-purifying respirator (PAPR) with coverall may be more protective than N95 masks and gown (RR 0.27), but create unique donning challenges.
- Long-gowns may be better than a coverall, but are also more difficult to doff. Gowns are better than aprons. Better sealing, fitting, and one-piece removal at gown-glove interfaces and closer fit around the neck may reduce exposure.
- Double-gloving may reduce exposure.
- Better training, computer simulation, video lectures, following CDC protocols, and spoken instruction may improve donning and doffing compliance.
Toronto anaesthesiologists Muñoz-Leyva & Niazi share observations from PPE training simulations, identifying the 'high risk' moments where frequent exposures and PPE failures are seen.
Why is this important?
For all the understandable concern over adequate access to PPE and discussion of appropriate levels of protection, HCW safety is entirely dependent on the effective use of this protective equipment.
Identifying common areas of 'biosafety breach' allows both clinicians and PPE supervisors to apply added attention to these steps. These areas can be conceptualised as offering a disproportionate safety benefit for the time and resources deployed in ensuring compliance at these moments.
Which areas did they identify as most important?
- N95 mask fit-testing and fit-checking; notably shaving facial hair to ensure a face-mask interface seal.
- Use of extended-cuff gloves with gown cuff tucked securely into glove.
- Time management: PPE donning should never be rushed, even in critical medical emergencies.
- Glove removal is a high-risk step. When removing the second, inner glove, ensure as little contact as possible with the glove sleeve by the ungloved hand.
- Gown removal is the next highest risk step. Do not touch the front of the gown, especially with ungloved hands.
- Mask removal avoid touching front of mask; avoid any snapping of straps.
- Perform alcohol-based hand-hygiene after each article is removed.
Randomized Controlled Trial
This relatively small study (N=19) randomised emergency resident trainees (14) and first responders (5) to cadaveric intubation with and without 'Level C PPE':
Level C PPE typically includes a full face mask with air respirator, a hooded chemical resistant clothing, inner and outer gloves and chemical resistant boots with covers.
First-pass intubation success was significant lower (58% vs 96%) while wearing PPE than without. Subjects identified the visibility impact of wearing protective hoods as the most common impediment to intubation.summary
In this review, Wilson, Norton, Young & Collins challenge the overly-simplistic view that SARS-CoV-2 transmission risk can be easily divided between droplet-contact and aerosol precautions.
Why is this important?
Many national societies have policies on Personal Protective Equipment (PPE) guided by classification of COVID exposure into aerosol-generation procedures (AGP) or other exposures. Although founded in some evidence, there are questions as to whether PPE shortage and availability also drives these recommendations. Widespread concern over healthcare worker (HCW) infection is understandable, given that during SARS 20% of infections were among HCWs.
Understanding the science behind respiratory particle generation and transmission helps to inform our understanding of how best to use limited PPE.
On the science of respiratory shedding
Aerosol generation is important because virus inhalation and deposition in small distal airways may be associated with greater infection risk and disease severity. Wilson et al. describe three mechanisms of aerosol generation:
- Laryngeal activity - talking, coughing, sneezing.
- High velocity gas flow - eg. high-flow oxygen
- Cyclical opening & closing of terminal airways.
Notably, the clinically features of COVID itself make all three high-risk mechanisms more likely. Additionally various studies show that even talking and tidal volume breathing produce large numbers and size ranges of respiratory droplets.
Exposure relative risk is primarily about proximity and exposure duration
Further, considering retrospective data form SARS HCW infections involving various procedures (eg. intubation, HCW infection RR 4.2; oxygen mask manipulation RR 9; urinary catheterisation RR 5), Wilson et al. propose that healthcare work risk can be considered:
infection risk ∝ 𝑏 × 𝑣 × 𝑡 / 𝑒
Where: 𝑏 = breathing zone particle viable virion aerosol concentration, 𝑣 = minute volume of healthcare worker, 𝑡 = time exposed , 𝑒 = mask efficiency
And on intubation:
"...[other] healthcare workers should stand over 2 m away and out of the direct exhalation plume. During a rapid sequence intubation muscle relaxation should be protective as coughing will be prevented and high airway gas flow and expiratory output will terminate. When expiratory flow is ended ... aerosol particles should start settling in the airways. The forces generated in gentle laryngoscopy are unlikely to cause aerosol formation."
"...[there is] limited evidence to suggest AGPs cause an increase in airborne healthcare worker transmission as this has not been studied. The few studies to sample pathogenic airborne particles in relation to procedures show no increase with the majority of AGPs."
Bear in mind...
Much of the evidence guiding our understanding of SARS-CoV-2 transmission is founded on understanding and research focusing on the 2003 SARS pandemic (SARS-CoV-1) and influenza research. Although sharing similarities, "...each has its own infective inoculum and aerosol characteristics."
What's the bottom-line?
Transmission of SARS-CoV-2 should be conceptualised as a spectrum of risk where time exposed may be the dominant factor and droplet-airborne spread is a complex continuum of varying probability of infection. Many 'non-AGP' events could in fact be higher risk than those traditionally considered AGP, such as intubation.summary
Previous meta-analyses concluded that there was insufficient evidence to determine the effect of N95 respirators. We aimed to assess the effectiveness of N95 respirators versus surgical masks for prevention of influenza by collecting randomized controlled trials (RCTs). ⋯ The use of N95 respirators compared with surgical masks is not associated with a lower risk of laboratory-confirmed influenza. It suggests that N95 respirators should not be recommended for general public and nonhigh-risk medical staff those are not in close contact with influenza patients or suspected patients.
Review Meta Analysis
There is uncertainty about the mode of transmission of the severe acute respiratory syndrome (SARS) virus. We analyzed the temporal and spatial distributions of cases in a large community outbreak of SARS in Hong Kong and examined the correlation of these data with the three-dimensional spread of a virus-laden aerosol plume that was modeled using studies of airflow dynamics. ⋯ Airborne spread of the virus appears to explain this large community outbreak of SARS, and future efforts at prevention and control must take into consideration the potential for airborne spread of this virus.
The world is currently facing an unprecedented healthcare crisis caused by a pandemic novel beta coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The pathogen is spread by human-to-human transmission via droplets exposure and contact transfer, causing mild symptoms in the majority of cases, but critical illness, bilateral viral pneumonia, and acute respiratory distress syndrome (ARDS) in a minority. ⋯ This article presents a summary of learning points in epidemiological infection control from the SARS epidemic, alongside a review of evidence connecting current understanding of the virologic and environmental contamination properties of SARS-CoV-2. We present suggestions for how personal protective equipment policies relate to the viral pandemic context and how the risk of transmission by and to anaesthetists, intensivists, and other healthcare workers can be minimised.
The COVID-19 pandemic has led to the manufacturing of novel devices to protect clinicians from the risk of transmission, including the aerosol box for use in intubation. We evaluated the impact of two aerosol boxes (an early-generation box and a latest-generation box) on intubations in patients with severe COVID-19 with an in-situ simulation crossover study. The simulated process complied with the Safe Airway Society COVID-19 airway management guidelines. ⋯ Aerosol boxes may increase intubation times and therefore expose patients to the risk of hypoxia. They may cause damage to conventional personal protective equipment and therefore place clinicians at risk of infection. Further research is required before these devices can be considered safe for clinical use.