Article Notes
- 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.
- Laryngeal activity - talking, coughing, sneezing.
- High velocity gas flow - eg. high-flow oxygen
- Cyclical opening & closing of terminal airways.
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.
Daniel Jolley
This is the second update to Verbeek et al.'s 2016 Cochrane Review of personal protective equipment (PPE) for preventing infections in healthcare workers (HCW). The prior update was in July 2019.
What's worth knowing?
Overall most studies of PPE efficacy are of low quality and offer a low certainty of conclusions. Caveat emptor...
Daniel Jolley
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:
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.
Daniel Jolley