Embracing the robotic revolution into anaesthetic practice

Use of powered air-purifying respirator(PAPR) as part of protective equipment against SARS-CoV-2-a narrative review and critical appraisal of evidence

BACKGROUND

The last 2 decades have seen an increasing frequency of zoonotic origin viral diseases leaping from animal to human hosts including Severe Acute Respiratory Syndrome Coronaviruses (SARS-CoV-2). Respiratory component of the infectious disease program against SARS-CoV-2 incorporates use of protective airborne respiratory equipment.

METHODS

In this narrative review, we explore the features of Powered Air Purifying Respirators (PAPR) as well as logistical and evidence-based advantages and disadvantages.

RESULTS

Simulation study findings support increased heat tolerance and wearer comfort with a PAPR, versus decreased communication ability, mobility, and dexterity. Although PAPRs have been recommended for high-risk procedures on suspected or confirmed COVID-19 patients, this recommendation remains controversial due to lack of evidence. Guidelines for appropriate use of PAPR during the current pandemic are sparse. International regulatory bodies do not mandate the use of PAPR for high-risk aerosol generating procedures in patients with SARS-CoV-2. Current reports of the choice of protective respiratory technology during the SARS-CoV-2 pandemic are disparate. Patterns of use appear to be related to geographical locations.

DISCUSSION

Field observational studies do not indicate a difference in healthcare worker infection utilizing PAPR devices versus other compliant respiratory equipment in healthcare workers performing AGPs in patients with SARS-CoV-2. Whether a higher PAPR filtration factor translates to decreased infection rates of HCWs remains to be elucidated. Utilization of PAPR with high filtration efficiency may represent an example of "precautionary principle" wherein action taken to reduce risk is guided by logistical advantages of PAPR system.

The use of artificial intelligence and robotics in regional anaesthesia

The current fourth industrial revolution is a distinct technological era characterised by the blurring of physics, computing and biology. The driver of change is data, powered by artificial intelligence. The UK National Health Service Topol Report embraced this digital revolution and emphasised the importance of artificial intelligence to the health service. Application of artificial intelligence within regional anaesthesia, however, remains limited. An example of the use of a convoluted neural network applied to visual detection of nerves on ultrasound images is described. New technologies that may impact on regional anaesthesia include robotics and artificial sensing. Robotics in anaesthesia falls into three categories. The first, used commonly, is pharmaceutical, typified by target-controlled anaesthesia using electroencephalography within a feedback loop. Other types include mechanical robots that provide precision and dexterity better than humans, and cognitive robots that act as decision support systems. It is likely that the latter technology will expand considerably over the next decades and provide an autopilot for anaesthesia. Technical robotics will focus on the development of accurate sensors for training that incorporate visual and motion metrics. These will be incorporated into augmented reality and visual reality environments that will provide training at home or the office on life-like simulators. Real-time feedback will be offered that stimulates and rewards performance. In discussing the scope, applications, limitations and barriers to adoption of these technologies, we aimed to stimulate discussion towards a framework for the optimal application of current and emerging technologies in regional anaesthesia.

Use of powered air-purifying respirator (PAPR) by healthcare workers for preventing highly infectious viral diseases-a systematic review of evidence

BACKGROUND

Healthcare workers (HCWs) are at particular risk during pandemics and epidemics of highly virulent diseases with significant morbidity and case fatality rate. These diseases include severe acute respiratory syndrome coronaviruses, SARS-CoV-1 and SARS-CoV-2, Middle Eastern Respiratory Syndrome (MERS), and Ebola. With the current (SARS-CoV-2) global pandemic, it is critical to delineate appropriate contextual respiratory protection for HCWs. The aim of this systematic review was to evaluate the effect of powered air-purifying respirators (PAPRs) as part of respiratory protection versus another device (egN95/FFP2) on HCW infection rates and contamination.

METHODS

Our primary outcomes included HCW infection rates with SARS-CoV-2, SARS-CoV-1, Ebola, or MERS when utilizing PAPR. We included randomized controlled trials, non-randomized controlled trials, and observational studies. We searched the following databases: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers independently screened all citations, full-text articles, and abstracted data. Due to clinical and methodological heterogeneity, we did not conduct a meta-analysis. Where applicable, we constructed evidence profile (EP) tables for each individual outcome. Confidence in cumulative evidence for each outcome was classified according to the GRADE system.

RESULTS

We identified 689 studies during literature searches. We included 10 full-text studies. A narrative synthesis was provided. Two on-field studies reported no difference in the rates of healthcare workers performing airway procedures during the care of critical patients with SARS-CoV-2. A single simulation trial reported a lower level of cross-contamination of participants using PAPR compared to alternative respiratory protection. There is moderate quality evidence that PAPR use is associated with greater heat tolerance but lower scores for mobility and communication ability. We identified a trend towards greater self-reported wearer comfort with PAPR technology in low-quality observational simulation studies.

CONCLUSION

Field observational studies do not indicate a difference in healthcare worker infection utilizing PAPR devices versus other compliant respiratory equipment. Greater heat tolerance accompanied by lower scores of mobility and audibility in PAPR was identified. Further pragmatic studies are needed in order to delineate actual effectiveness and provider satisfaction with PAPR technology.

SYSTEMATIC REVIEW REGISTRATION

The protocol for this review was prospectively registered with the International Register of Systematic Reviews identification number CRD42020184724 .