Project description:Aerosol generating procedures (AGPs) may expose health care workers (HCWs) to pathogens causing acute respiratory infections (ARIs), but the risk of transmission of ARIs from AGPs is not fully known. We sought to determine the clinical evidence for the risk of transmission of ARIs to HCWs caring for patients undergoing AGPs compared with the risk of transmission to HCWs caring for patients not undergoing AGPs. We searched PubMed, EMBASE, MEDLINE, CINAHL, the Cochrane Library, University of York CRD databases, EuroScan, LILACS, Indian Medlars, Index Medicus for SE Asia, international health technology agencies and the Internet in all languages for articles from 01/01/1990 to 22/10/2010. Independent reviewers screened abstracts using pre-defined criteria, obtained full-text articles, selected relevant studies, and abstracted data. Disagreements were resolved by consensus. The outcome of interest was risk of ARI transmission. The quality of evidence was rated using the GRADE system. We identified 5 case-control and 5 retrospective cohort studies which evaluated transmission of SARS to HCWs. Procedures reported to present an increased risk of transmission included [n; pooled OR(95%CI)] tracheal intubation [n?=?4 cohort; 6.6 (2.3, 18.9), and n?=?4 case-control; 6.6 (4.1, 10.6)], non-invasive ventilation [n?=?2 cohort; OR 3.1(1.4, 6.8)], tracheotomy [n?=?1 case-control; 4.2 (1.5, 11.5)] and manual ventilation before intubation [n?=?1 cohort; OR 2.8 (1.3, 6.4)]. Other intubation associated procedures, endotracheal aspiration, suction of body fluids, bronchoscopy, nebulizer treatment, administration of O2, high flow O2, manipulation of O2 mask or BiPAP mask, defibrillation, chest compressions, insertion of nasogastric tube, and collection of sputum were not significant. Our findings suggest that some procedures potentially capable of generating aerosols have been associated with increased risk of SARS transmission to HCWs or were a risk factor for transmission, with the most consistent association across multiple studies identified with tracheal intubation.
Project description:The transmission behaviour of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is still being defined. It is likely that it is transmitted predominantly by droplets and direct contact and it is possible that there is at least opportunistic airborne transmission. In order to protect healthcare staff adequately it is necessary that we establish whether aerosol-generating procedures (AGPs) increase the risk of transmission of SARS-CoV-2. Where we do not have evidence relating to SARS-CoV-2, guidelines for safely conducting these procedures should consider the risk of transmitting related pathogens. Currently there is very little evidence detailing the transmission of SARS-CoV-2 associated with any specific procedures. Regarding AGPs and respiratory pathogens in general, there is still a large knowledge gap that will leave clinicians unsure of the risk to themselves when offering these procedures. This review aimed to summarize the evidence (and gaps in evidence) around AGPs and SARS-CoV-2.
Project description:PurposeThe aim of this study was to compare aerosol exposure with or without an aerosol box in a pressurized/depressurized room during aerosol-generating procedures using an experimental model.MethodsCake flour (aerosol model) was expelled from an advanced life support training mannequin. The primary outcome measure was the number of 0.3-10 µm-sized particles at three locations corresponding to the physician, medical staff, and environmental aerosol exposure levels. The aerosol dispersion was visualized using a high-resolution video. The number of expelled particles was measured after artificial coughing during simulated tracheal intubation and extubation in four situations, with or without an aerosol box in a pressurized or depressurized room (≤ 2.5 Pa).ResultsThe particles arising from tracheal intubation at the three positions in the four groups differed significantly in size (p < 0.05). The sizes of particles arising from extubation at the physicians' and medical staff's faces in the four groups differed significantly in size (p < 0.05). Post hoc analysis showed that the counts of all particles at the three positions were significantly lower in the depressurized room with an aerosol box than in the pressurized room without an aerosol box during tracheal intubation (p < 0.05 at three positions) and extubation (p < 0.05) at the physician's and medical staff's positions). Visual assessments supported these results.ConclusionThe aerosol box decreased the exposure of the aerosol to the physician, medical staff, and environment during aerosol-generating procedures in the depressurized room only.
Project description:BackgroundDuring medical procedures with the potential to produce aerosols such as bronchoscopy, intubation, or CPR, health-care workers (HCWs) may be exposed to infectious bioaerosols. This scenario is of particular concern when high consequence pathogens such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are circulating. Thousands of HCWs have been infected with SARS-CoV-2. However, the determinants of aerosol generation during medical procedures and their relative risk to HCWs remain poorly characterized.Research questionThe goal of this study was to characterize aerosols produced during airway intubation by using an uninfected translational animal model and in human subjects undergoing elective aerosol-generating procedures. The study also determined the particle size distribution of generated particles.Study design and methodsAerosol generation was measured during highly controlled experimental (pig) intubations (N = 16) and elective bronchoscopies in uninfected patients (N = 49) using an optical particle counter. Recovery of normal respiratory flora was used as a surrogate for pathogen dispersion.ResultsThere was a small but significant (P = .03) decrease in 0.3 μm size particles during highly controlled pig intubations compared with baseline. The concentration of 1.0 μm and 5.0 μm aerosol particles did not significantly change, although oral bacteria were collected from the air. For elective patient bronchoscopies, there was a significant decrease in the generation of larger particles (1.0 μm and 5.0 μm) compared with baseline (P < .01); however, 18 of 39 (46%) patients showed increased aerosol production in 0.3 μm size particles, four of whom exhibited measurable increases.InterpretationAlthough the total amount of aerosols produced during intubation and bronchoscopy did not increase significantly relative to preprocedural levels, a small number of participants exhibited a measurable increase in submicron particle emission, meriting further research to delineate determinants of fine particle production during aerosol-generating procedures.
Project description:ObjectivesThis study evaluated particle spread associated with various common periodontal aerosol-generating procedures (AGPs) in simulated and clinical settings.Materials and methodsA simulation study visualized the aerosols, droplets, and splatter spread with and without high-volume suction (HVS, 325 L/min) during common dental AGPs, namely ultrasonic scaling, air flow prophylaxis, and implant drilling after fluorescein dye was added to the water irrigant as a tracer. Each procedure was repeated 10 times. A complementary clinical study measured the spread of contaminated particles within the dental operatory and quantified airborne protein dispersion following 10 min of ultrasonic supragingival scaling of 19 participants during routine periodontal treatment.ResultsThe simulation study data showed that air flow produced the highest amount of splatters and the ultrasonic scaler generated the most aerosol and droplet particles at 1.2 m away from the source. The use of HVS effectively reduced 37.5-96% of splatter generation for all three dental AGPs, as well as 82-93% of aerosol and droplet particles at 1.2 m for the ultrasonic scaler and air polisher. In the clinical study, higher protein levels above background levels following ultrasonic supragingival scaling were detected in fewer than 20% of patients, indicating minimal particle spread.ConclusionsWhile three common periodontal AGPs produce aerosols and droplet particles up to at least 1.2 m from the source, the use of HVS is of significant benefit. Routine ultrasonic supragingival scaling produced few detectable traces of salivary protein at various sites throughout the 10-min dental operatory.Clinical relevanceThe likelihood of aerosol spread to distant sites during common periodontal AGPs is greatly reduced by high-volume suction. Clinically, limited evidence of protein contaminants was found following routine ultrasonic scaling, suggesting that the the majority of the contamination consisits of the irrigant rather than organic matter from the oral cavity.
Project description:BackgroundCOVID-19 infection poses a serious risk to patients and - due to its contagious nature - to those healthcare workers (HCWs) treating them. The risks of transmission of infection are greater when a patient is undergoing an aerosol-generating procedure (AGP). Not all those with COVID-19 infection are symptomatic, or suspected of harbouring the infection. If a patient who is not known to have or suspected of having COVID-19 infection is to undergo an AGP, it would nonetheless be sensible to minimise the risk to those HCWs treating them. If the mouth and nose of an individual undergoing an AGP are irrigated with antimicrobial solutions, this may be a simple and safe method of reducing the risk of any covert infection being passed to HCWs through droplet transmission or direct contact. Alternatively, the use of antimicrobial solutions by the HCW may decrease the chance of them acquiring COVID-19 infection. However, the use of such antimicrobial solutions may be associated with harms related to the toxicity of the solutions themselves or alterations in the natural microbial flora of the mouth or nose.ObjectivesTo assess the benefits and harms of antimicrobial mouthwashes and nasal sprays administered to HCWs and/or patients when undertaking AGPs on patients without suspected or confirmed COVID-19 infection.Search methodsInformation Specialists from Cochrane ENT and Cochrane Oral Health searched the Central Register of Controlled Trials (CENTRAL 2020, Issue 6); Ovid MEDLINE; Ovid Embase and additional sources for published and unpublished trials. The date of the search was 1 June 2020. SELECTION CRITERIA: This is a question that urgently requires evidence, however at the present time we did not anticipate finding many completed RCTs. We therefore planned to include the following types of studies: randomised controlled trials (RCTs); quasi-RCTs; non-randomised controlled trials; prospective cohort studies; retrospective cohort studies; cross-sectional studies; controlled before-and-after studies. We set no minimum duration for the studies. We sought studies comparing any antimicrobial mouthwash and/or nasal spray (alone or in combination) at any concentration, delivered to the patient or HCW before and/or after an AGP.Data collection and analysisWe used standard Cochrane methodological procedures. Our primary outcomes were: 1) incidence of symptomatic or test-positive COVID-19 infection in HCWs or patients; 2) significant adverse event: anosmia (or disturbance in sense of smell). Our secondary outcomes were: 3) COVID-19 viral content of aerosol (when present); 4) change in COVID-19 viral load at site(s) of irrigation; 5) other adverse events: changes in microbiome in oral cavity, nasal cavity, oro- or nasopharynx; 6) other adverse events: allergy, irritation/burning of nasal, oral or oropharyngeal mucosa (e.g. erosions, ulcers, bleeding), long-term staining of mucous membranes or teeth, accidental ingestion. We planned to use GRADE to assess the certainty of the evidence for each outcome.Main resultsWe found no completed studies to include in this review. AUTHORS' CONCLUSIONS: We identified no studies for inclusion in this review, nor any ongoing studies. The absence of completed studies is not surprising given the relatively recent emergence of COVID-19 infection. However, we are disappointed that this important clinical question is not being addressed by ongoing studies.
Project description:The world is going through the COVID-19 pandemic, which has high virulence and transmission rate. More significant the viral load during exposure, the greater is the likelihood of contracting a severe disease. Healthcare workers (HCWs) involved in airway care of COVID-19 patients are at high risk of getting exposed to large viral loads during aerosol-generating actions such as coughing or sneezing by the patient or during procedures such as bag-mask ventilation, intubation, extubation, and nebulization. This viral load exposure to airway caregivers decreases considerably with the use of an aerosol box during intubation. The safety tent proposed in this article is useful in limiting the viral load that HCWs are exposed to during airway procedures. Its role can be expanded beyond just intubation to protect against all aerosol-generating actions and procedures involving the patient's airway.