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Lyons C, Jonsson Fagerlund M, Patel A. High-flow Nasal Oxygen: Physiology and Clinical Applications. Int Anesthesiol Clin 2024; 62:72-81. [PMID: 39233573 DOI: 10.1097/aia.0000000000000449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Affiliation(s)
- Craig Lyons
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Malin Jonsson Fagerlund
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Anil Patel
- Department of Anaesthesia, University College London Hospitals NHS Foundation Trust, London, UK
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2
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Vincent R, Rapoport D, Balchandani P, Borrello J, Schotsaert M, Karlicek R, Laghlali G, Warang P, Park S, Singh G, Morgan I, Paredes J, Rathnasinghe R, Wolf J, Garcia-Sastre A. Portable UV-C Device to Treat High Flow of Infectious Aerosols Generated during Clinical Respiratory Care. RESEARCH SQUARE 2024:rs.3.rs-4648863. [PMID: 39108476 PMCID: PMC11302707 DOI: 10.21203/rs.3.rs-4648863/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
Respiratory interventions including noninvasive ventilation, continuous positive airway pressure and high-flow nasal oxygen generated infectious aerosols may increase risk of airborne disease (SARS-CoV-2, influenza virus) transmission to healthcare workers. We developed/tested a prototype portable UV-C254 device to sterilize high flows of viral-contaminated air from a simulated patient source at airflow rates of up to 100 l/m. Our device consisted of a central quartz tube surrounded 6 high-output UV-C254 lamps, within a larger cylinder allowing recirculation past the UV-C254 lamps a second time before exiting the device. Testing was with nebulized A/PR/8/34 (H1N1) influenza virus. RNA extraction and qRT-PCR showed virus transited through the prototype. Turning on varying numbers of lamps controlled the dose of UVC. Viability experiments at low, medium and high (100 l/min) flows of contaminated gas were conducted with 6, 4, 2 and 1 lamp activated (single-pass and recirculation were tested). Our data show 5-log reduction in particle forming units from a single lamp (single- pass and recirculated conditions) at high and low flows. UVC dose at 100 l/m was calculated at 11.6 mJ/cm2 single pass and 104 mJ/cm2 recirculated. The protype device shows high efficacy in killing nebulized influenza virus in a high flow of contaminated air.
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Klompas M. Ventilator-Associated Pneumonia, Ventilator-Associated Events, and Nosocomial Respiratory Viral Infections on the Leeside of the Pandemic. Respir Care 2024; 69:854-868. [PMID: 38806219 DOI: 10.4187/respcare.11961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
The COVID-19 pandemic has had an unprecedented impact on population health and hospital operations. Over 7 million patients have been hospitalized for COVID-19 thus far in the United States alone. Mortality rates for hospitalized patients during the first wave of the pandemic were > 30%, but as we enter the fifth year of the pandemic hospitalizations have fallen and mortality rates for hospitalized patients with COVID-19 have plummeted to 5% or less. These gains reflect lessons learned about how to optimize respiratory support for different kinds of patients, targeted use of therapeutics for patients with different manifestations of COVID-19 including immunosuppressants and antivirals as appropriate, and high levels of population immunity acquired through vaccines and natural infections. At the same time, the pandemic has helped highlight some longstanding sources of harm for hospitalized patients including hospital-acquired pneumonia, ventilator-associated events (VAEs), and hospital-acquired respiratory viral infections. We are, thankfully, on the leeside of the pandemic at present; but the large increases in ventilator-associated pneumonia (VAP), VAEs, bacterial superinfections, and nosocomial respiratory viral infections associated with the pandemic beg the question of how best to prevent these complications moving forward. This paper reviews the burden of hospitalization for COVID-19, the intersection between COVID-19 and both VAP and VAEs, the frequency and impact of hospital-acquired respiratory viral infections, new recommendations on how best to prevent VAP and VAEs, and current insights into effective strategies to prevent nosocomial spread of respiratory viruses.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts; and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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4
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Greenhalgh T, MacIntyre CR, Baker MG, Bhattacharjee S, Chughtai AA, Fisman D, Kunasekaran M, Kvalsvig A, Lupton D, Oliver M, Tawfiq E, Ungrin M, Vipond J. Masks and respirators for prevention of respiratory infections: a state of the science review. Clin Microbiol Rev 2024; 37:e0012423. [PMID: 38775460 PMCID: PMC11326136 DOI: 10.1128/cmr.00124-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
SUMMARYThis narrative review and meta-analysis summarizes a broad evidence base on the benefits-and also the practicalities, disbenefits, harms and personal, sociocultural and environmental impacts-of masks and masking. Our synthesis of evidence from over 100 published reviews and selected primary studies, including re-analyzing contested meta-analyses of key clinical trials, produced seven key findings. First, there is strong and consistent evidence for airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other respiratory pathogens. Second, masks are, if correctly and consistently worn, effective in reducing transmission of respiratory diseases and show a dose-response effect. Third, respirators are significantly more effective than medical or cloth masks. Fourth, mask mandates are, overall, effective in reducing community transmission of respiratory pathogens. Fifth, masks are important sociocultural symbols; non-adherence to masking is sometimes linked to political and ideological beliefs and to widely circulated mis- or disinformation. Sixth, while there is much evidence that masks are not generally harmful to the general population, masking may be relatively contraindicated in individuals with certain medical conditions, who may require exemption. Furthermore, certain groups (notably D/deaf people) are disadvantaged when others are masked. Finally, there are risks to the environment from single-use masks and respirators. We propose an agenda for future research, including improved characterization of the situations in which masking should be recommended or mandated; attention to comfort and acceptability; generalized and disability-focused communication support in settings where masks are worn; and development and testing of novel materials and designs for improved filtration, breathability, and environmental impact.
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Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - C Raina MacIntyre
- Biosecurity Program, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Shovon Bhattacharjee
- Biosecurity Program, The Kirby Institute, University of New South Wales, Sydney, Australia
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, Australia
| | - Abrar A Chughtai
- School of Population Health, University of New South Wales, Sydney, Australia
| | - David Fisman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Mohana Kunasekaran
- Biosecurity Program, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Amanda Kvalsvig
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Deborah Lupton
- Centre for Social Research in Health and Social Policy Research Centre, Faculty of Arts, Design and Architecture, University of New South Wales, Sydney, Australia
| | - Matt Oliver
- Professional Standards Advocate, Edmonton, Canada
| | - Essa Tawfiq
- Biosecurity Program, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mark Ungrin
- Faculty of Veterinary Medicine; Department of Biomedical Engineering, Schulich School of Engineering; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Joe Vipond
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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5
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Atamer Balkan B, Chang Y, Sparnaaij M, Wouda B, Boschma D, Liu Y, Yuan Y, Daamen W, de Jong MCM, Teberg C, Schachtschneider K, Sikkema RS, van Veen L, Duives D, ten Bosch QA. The multi-dimensional challenges of controlling respiratory virus transmission in indoor spaces: Insights from the linkage of a microscopic pedestrian simulation and SARS-CoV-2 transmission model. PLoS Comput Biol 2024; 20:e1011956. [PMID: 38547311 PMCID: PMC11003685 DOI: 10.1371/journal.pcbi.1011956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 04/09/2024] [Accepted: 02/29/2024] [Indexed: 04/11/2024] Open
Abstract
SARS-CoV-2 transmission in indoor spaces, where most infection events occur, depends on the types and duration of human interactions, among others. Understanding how these human behaviours interface with virus characteristics to drive pathogen transmission and dictate the outcomes of non-pharmaceutical interventions is important for the informed and safe use of indoor spaces. To better understand these complex interactions, we developed the Pedestrian Dynamics-Virus Spread model (PeDViS), an individual-based model that combines pedestrian behaviour models with virus spread models incorporating direct and indirect transmission routes. We explored the relationships between virus exposure and the duration, distance, respiratory behaviour, and environment in which interactions between infected and uninfected individuals took place and compared this to benchmark 'at risk' interactions (1.5 metres for 15 minutes). When considering aerosol transmission, individuals adhering to distancing measures may be at risk due to the buildup of airborne virus in the environment when infected individuals spend prolonged time indoors. In our restaurant case, guests seated at tables near infected individuals were at limited risk of infection but could, particularly in poorly ventilated places, experience risks that surpass that of benchmark interactions. Combining interventions that target different transmission routes can aid in accumulating impact, for instance by combining ventilation with face masks. The impact of such combined interventions depends on the relative importance of transmission routes, which is hard to disentangle and highly context dependent. This uncertainty should be considered when assessing transmission risks upon different types of human interactions in indoor spaces. We illustrated the multi-dimensionality of indoor SARS-CoV-2 transmission that emerges from the interplay of human behaviour and the spread of respiratory viruses. A modelling strategy that incorporates this in risk assessments can help inform policy makers and citizens on the safe use of indoor spaces with varying inter-human interactions.
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Affiliation(s)
- Büsra Atamer Balkan
- Quantitative Veterinary Epidemiology, Wageningen University & Research, Wageningen, The Netherlands
| | - You Chang
- Quantitative Veterinary Epidemiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Martijn Sparnaaij
- Department of Transport & Planning, Delft University of Technology, Delft, The Netherlands
| | - Berend Wouda
- Gamelab, Delft University of Technology, Delft, The Netherlands
| | - Doris Boschma
- Gamelab, Delft University of Technology, Delft, The Netherlands
| | - Yangfan Liu
- Quantitative Veterinary Epidemiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Yufei Yuan
- Department of Transport & Planning, Delft University of Technology, Delft, The Netherlands
| | - Winnie Daamen
- Department of Transport & Planning, Delft University of Technology, Delft, The Netherlands
| | - Mart C. M. de Jong
- Quantitative Veterinary Epidemiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Colin Teberg
- Steady State Scientific Computing, Chicago, Illinois, United States of America
| | | | | | - Linda van Veen
- Gamelab, Delft University of Technology, Delft, The Netherlands
| | - Dorine Duives
- Department of Transport & Planning, Delft University of Technology, Delft, The Netherlands
| | - Quirine A. ten Bosch
- Quantitative Veterinary Epidemiology, Wageningen University & Research, Wageningen, The Netherlands
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6
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Wilson NM, Calabria C, Warren A, Finlay A, O'Donovan A, Passerello GL, Ribaric NL, Ward P, Gillespie R, Farrel R, McNarry AF, Pan D. Quantifying hospital environmental ventilation using carbon dioxide monitoring - a multicentre study. Anaesthesia 2024; 79:147-155. [PMID: 38059394 DOI: 10.1111/anae.16124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 12/08/2023]
Abstract
The COVID-19 pandemic has highlighted the importance of environmental ventilation in reducing airborne pathogen transmission. Carbon dioxide monitoring is recommended in the community to ensure adequate ventilation. Dynamic measurements of ventilation quantifying human exhaled waste gas accumulation are not conducted routinely in hospitals. Instead, environmental ventilation is allocated using static hourly air change rates. These vary according to the degree of perceived hazard, with the highest change rates reserved for locations where aerosol-generating procedures are performed, where medical/anaesthetic gases are used and where a small number of high-risk infective or immunocompromised patients may be isolated to reduce cross-infection. We aimed to quantify the quality and distribution of ventilation in hospital by measuring carbon dioxide levels in a two-phased prospective observational study. First, under controlled conditions, we validated our method and the relationship between human occupancy, ventilation and carbon dioxide levels using non-dispersive infrared carbon dioxide monitors. We then assessed ventilation quality in patient-occupied (clinical) and staff break and office (non-clinical) areas across two hospitals in Scotland. We selected acute medical and respiratory wards in which patients with COVID-19 are cared for routinely, as well as ICUs and operating theatres where aerosol-generating procedures are performed routinely. Between November and December 2022, 127,680 carbon dioxide measurements were obtained across 32 areas over 8 weeks. Carbon dioxide levels breached the 800 ppm threshold for 14% of the time in non-clinical areas vs. 7% in clinical areas (p < 0.001). In non-clinical areas, carbon dioxide levels were > 800 ppm for 20% of the time in both ICUs and wards, vs. 1% in operating theatres (p < 0.001). In clinical areas, carbon dioxide was > 800 ppm for 16% of the time in wards, vs. 0% in ICUs and operating theatres (p < 0.001). We conclude that staff break, office and clinical areas on acute medical and respiratory wards frequently had inadequate ventilation, potentially increasing the risks of airborne pathogen transmission to staff and patients. Conversely, ventilation was consistently high in the ICU and operating theatre clinical environments. Carbon dioxide monitoring could be used to measure and guide improvements in hospital ventilation.
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Affiliation(s)
- N M Wilson
- Department of Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - C Calabria
- Department of Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A Warren
- Department of Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A Finlay
- Department of Anaesthesia and Critical Care, Victoria Hospital, Kirkcaldy, UK
| | - A O'Donovan
- Department of Process, Energy and Transport Engineering, MeSSO Research Group, Munster Technological University, Cork, Ireland
| | - G L Passerello
- Department of Anaesthesia and Critical Care, Victoria Hospital, Kirkcaldy, UK
| | - N L Ribaric
- Faculty of Medicine, University Medical Centre Hamburg-Eppendorf, University of Hamburg, Hamburg, Germany
| | - P Ward
- Department of Anaesthesia, St John's Hospital, Livingston, UK
| | - R Gillespie
- Department of Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - R Farrel
- Department of Anaesthesia and Critical Care, Victoria Hospital, Kirkcaldy, UK
| | - A F McNarry
- Department of Anaesthesia, Western General Hospital, UK
| | - D Pan
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Department of Infectious Diseases and HIV Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
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7
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Ward PA, Athanassoglou V, McNarry AF. Safe use of high flow nasal oxygen in apnoeic patients for laryngotracheal surgery: Adapting practice as technology evolves. Eur J Anaesthesiol 2023; 40:801-804. [PMID: 37789752 DOI: 10.1097/eja.0000000000001890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Affiliation(s)
- Patrick A Ward
- From St John's Hospital, NHS Lothian, Livingston (PAW, AFM), Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford (VA), and Western General Hospital, NHS Lothian, Edinburgh, UK (AFM)
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8
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Arunachala S, Parthasarathi A, Basavaraj CK, Malamardi S, Chandran S, Venkataraman H, Ullah MK, Ganguly K, Upadhyay S, Mahesh PA. The Use of High-Flow Nasal Cannula and Non-Invasive Mechanical Ventilation in the Management of COVID-19 Patients: A Prospective Study. Viruses 2023; 15:1879. [PMID: 37766286 PMCID: PMC10535869 DOI: 10.3390/v15091879] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/30/2023] [Accepted: 09/02/2023] [Indexed: 09/29/2023] Open
Abstract
High-flow nasal cannula (HFNC) and ventilator-delivered non-invasive mechanical ventilation (NIV) were used to treat acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia, especially in low- and middle-income countries (LMICs), due to lack of ventilators and manpower resources despite the paucity of data regarding their efficacy. This prospective study aimed to analyse the efficacy of HFNC versus NIV in the management of COVID-19 ARDS. A total of 88 RT-PCR-confirmed COVID-19 patients with moderate ARDS were recruited. Linear regression and generalized estimating equations (GEEs) were used for trends in vital parameters over time. A total of 37 patients were on HFNC, and 51 were on NIV. Patients in the HFNC group stayed slightly but not significantly longer in the ICU as compared to their NIV counterparts (HFNC vs. NIV: 8.00 (4.0-12.0) days vs. 7.00 (2.0-12.0) days; p = 0.055). Intubation rates, complications, and mortality were similar in both groups. The switch to HFNC from NIV was 5.8%, while 37.8% required a switch to NIV from HFNC. The resolution of respiratory alkalosis was better with NIV. We conclude that in patients with COVID-19 pneumonia with moderate ARDS, the duration of treatment in the ICU, intubation rate, and mortality did not differ significantly with the use of HFNC or NIV for respiratory support.
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Affiliation(s)
- Sumalatha Arunachala
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru 570015, India; (S.A.); (C.K.B.); (S.M.); (S.C.); (H.V.)
- Public Health Research Institute of India, Mysuru 570020, India
| | - Ashwaghosha Parthasarathi
- Allergy, Asthma, and Chest Centre, Krishnamurthy Puram, Mysuru 570004, India;
- RUTGERS Centre for Pharmacoepidemiology and Treatment Science, New Brunswick, NJ 08901, USA
| | - Chetak Kadabasal Basavaraj
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru 570015, India; (S.A.); (C.K.B.); (S.M.); (S.C.); (H.V.)
| | - Sowmya Malamardi
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru 570015, India; (S.A.); (C.K.B.); (S.M.); (S.C.); (H.V.)
- School of Psychology & Public Health, College of Science Health and Engineering, La Trobe University, Melbourne, VIC 3086, Australia
| | - Shreya Chandran
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru 570015, India; (S.A.); (C.K.B.); (S.M.); (S.C.); (H.V.)
| | - Hariharan Venkataraman
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru 570015, India; (S.A.); (C.K.B.); (S.M.); (S.C.); (H.V.)
| | - Mohammed Kaleem Ullah
- Centre for Excellence in Molecular Biology and Regenerative Medicine (A DST-FIST Supported Center), Department of Biochemistry (A DST-FIST Supported Department), JSS Medical College, JSS Academy of Higher Education and Research, Mysuru 570015, India;
- Division of Infectious Disease and Vaccinology, School of Public Health, University of California, Berkeley, CA 94720, USA
| | - Koustav Ganguly
- Unit of Integrative Toxicology, Institute of Environmental Medicine (IMM), Karolinska Institute, 17177 Stockholm, Sweden;
| | - Swapna Upadhyay
- Unit of Integrative Toxicology, Institute of Environmental Medicine (IMM), Karolinska Institute, 17177 Stockholm, Sweden;
| | - Padukudru Anand Mahesh
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru 570015, India; (S.A.); (C.K.B.); (S.M.); (S.C.); (H.V.)
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9
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Plachouras D, Kacelnik O, Rodríguez-Baño J, Birgand G, Borg MA, Kristensen B, Kubele J, Lyytikäinen O, Presterl E, Reilly J, Voss A, Zingg W, Suetens C, Monnet DL. Revisiting the personal protective equipment components of transmission-based precautions for the prevention of COVID-19 and other respiratory virus infections in healthcare. Euro Surveill 2023; 28:2200718. [PMID: 37561052 PMCID: PMC10416576 DOI: 10.2807/1560-7917.es.2023.28.32.2200718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 05/10/2023] [Indexed: 08/11/2023] Open
Abstract
The COVID-19 pandemic highlighted some potential limitations of transmission-based precautions. The distinction between transmission through large droplets vs aerosols, which have been fundamental concepts guiding infection control measures, has been questioned, leading to considerable variation in expert recommendations on transmission-based precautions for COVID-19. Furthermore, the application of elements of contact precautions, such as the use of gloves and gowns, is based on low-quality and inconclusive evidence and may have unintended consequences, such as increased incidence of healthcare-associated infections and spread of multidrug-resistant organisms. These observations indicate a need for high-quality studies to address the knowledge gaps and a need to revisit the theoretical background regarding various modes of transmission and the definitions of terms related to transmission. Further, we should examine the implications these definitions have on the following components of transmission-based precautions: (i) respiratory protection, (ii) use of gloves and gowns for the prevention of respiratory virus infections, (iii) aerosol-generating procedures and (iv) universal masking in healthcare settings as a control measure especially during seasonal epidemics. Such a review would ensure that transmission-based precautions are consistent and rationally based on available evidence, which would facilitate decision-making, guidance development and training, as well as their application in practice.
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Affiliation(s)
| | | | - Jesús Rodríguez-Baño
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases and Microbiology division, Hospital Universitario Virgen Macarena and Department of Medicine, University of Seville/CSIC, Biomedicine Institute of Seville, Seville, Spain
| | - Gabriel Birgand
- Health Protection Research Unit, Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, United Kingdom
- Regional Centre for Infection Prevention and Control, Region of Pays de la Loire, Nantes, France
| | - Michael A Borg
- Infection Control Department, Mater Dei Hospital, Msida, Malta
| | | | - Jan Kubele
- Clinical Microbiology and ATB centre, Na Homolce Hospital, Prague, Czechia
| | | | - Elisabeth Presterl
- Department for Hospital Epidemiology and Infection Control, Medical University of Vienna, Vienna, Austria
| | - Jacqui Reilly
- Research Centre for Health, Glasgow Caledonian University, Glasgow, United Kingdom
| | - Andreas Voss
- Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, Groningen, the Netherlands
| | - Walter Zingg
- Charité Universitätsmedizin, Berlin, Germany
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Carl Suetens
- European Centre for Disease Prevention and Control, Stockholm, Sweden
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10
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Lin Y, Cheng A, Pirie J, Davidson J, Levy A, Matava C, Aubin CE, Robert E, Buyck M, Hecker K, Gravel G, Chang TP. Quantifying Simulated Contamination Deposition on Healthcare Providers Using Image Analysis. Simul Healthc 2023; 18:207-213. [PMID: 35561347 DOI: 10.1097/sih.0000000000000664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Simulation-based research has played an important role in improving care for communicable diseases. Unfortunately, few studies have attempted to quantify the level of contamination in these simulation activities. We aim to assess the feasibility and provide validity evidence for using integrated density values and area of contamination (AOC) to differentiate various levels of simulated contamination. METHODS An increasing number of simulated contamination spots using fluorescent marker were applied on a manikin chest to simulate a contaminated healthcare provider. An ultraviolet light was used to illuminate the manikin to highlight the simulated contamination. Images of increasing contamination levels were captured using a camera with different exposure settings. Image processing software was used to measure 2 outcomes: (1) natural logarithm of integrated density; and (2) AOC. Mixed-effects linear regression models were used to assess the effect of contamination levels and exposure settings on both outcome measures. A standardized "proof-of-concept" exercise was set up to calibrate and formalize the process for human subjects. RESULTS A total of 140 images were included in the analyses. Dose-response relationships were observed between contamination levels and both outcome measures. For each increment in the number of contaminated simulation spots (ie, simulated contaminated area increased by 38.5 mm 2 ), on average, log-integrated density increased by 0.009 (95% confidence interval, 0.006-0.012; P < 0.001) and measured AOC increased by 37.8 mm 2 (95% confidence interval, 36.7-38.8 mm 2 ; P < 0.001), which is very close to actual value (38.5 mm 2 ). The "proof-of-concept" demonstration further verified results. CONCLUSIONS Integrated density and AOC measured by image processing can differentiate various levels of simulated, fluorescent contamination. The AOC measured highly agrees with the actual value. This method should be optimized and used in the future research to detect simulated contamination deposited on healthcare providers.
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Affiliation(s)
- Yiqun Lin
- From the KidSIM Simulation Program (Y.L., J.D.), Alberta Children's Hospital; Departments of Pediatrics and Emergency Medicine (A.C.), University of Calgary, Calgary; Pediatric Emergency Medicine Simulation Program (J.P.), The Hospital for Sick Children University of Toronto, Toronto; Departments of Paediatric Emergency Medicine and Paediatrics (A.L., M.B.), University of Montréal Sainte-Justine's Hospital University Centre, Montréal; Department of Anesthesia and Pain Medicine (C.M.), The Hospital for Sick Children, Toronto; Department of Mechanical Engineering (C.-E.A., E.R.), Polytechnique Montréal, Montréal; Department of Veterinary Clinical and Diagnostic Sciences (K.H.), Faculty of Veterinary Medicine University of Calgary, Calgary; Department of Family Medicine and Emergency Medicine (G.G.), Laval University Laval University Hospital Center, Québec City, Canada; and Children's Hospital Los Angeles (T.P.C.), University of Southern California, Los Angeles, CA
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11
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Awatade NT, Wark PAB, Chan ASL, Mamun SMAA, Mohd Esa NY, Matsunaga K, Rhee CK, Hansbro PM, Sohal SS. The Complex Association between COPD and COVID-19. J Clin Med 2023; 12:jcm12113791. [PMID: 37297985 DOI: 10.3390/jcm12113791] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/26/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is significant cause of morbidity and mortality worldwide. There is mounting evidence suggesting that COPD patients are at increased risk of severe COVID-19 outcomes; however, it remains unclear whether they are more susceptible to acquiring SARS-CoV-2 infection. In this comprehensive review, we aim to provide an up-to-date perspective of the intricate relationship between COPD and COVID-19. We conducted a thorough review of the literature to examine the evidence regarding the susceptibility of COPD patients to COVID-19 infection and the severity of their disease outcomes. While most studies have found that pre-existing COPD is associated with worse COVID-19 outcomes, some have yielded conflicting results. We also discuss confounding factors such as cigarette smoking, inhaled corticosteroids, and socioeconomic and genetic factors that may influence this association. Furthermore, we review acute COVID-19 management, treatment, rehabilitation, and recovery in COPD patients and how public health measures impact their care. In conclusion, while the association between COPD and COVID-19 is complex and requires further investigation, this review highlights the need for careful management of COPD patients during the pandemic to minimize the risk of severe COVID-19 outcomes.
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Affiliation(s)
- Nikhil T Awatade
- Immune Health Program, Hunter Medical Research Institute and University of Newcastle, Newcastle 2305, Australia
| | - Peter A B Wark
- Immune Health Program, Hunter Medical Research Institute and University of Newcastle, Newcastle 2305, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle 2305, Australia
| | - Andrew S L Chan
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St. Leonards 2065, Australia
- Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
| | - S M Abdullah Al Mamun
- Department of Respiratory Medicine & Sleep Medicine, Evercare Hospitals Dhaka, Dhaka 1229, Bangladesh
| | | | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease Graduate School of Medicine, Yamaguchi University, 1-1-1 Minami-kogushi, Ube 755-8505, Japan
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Philip M Hansbro
- Immune Health Program, Hunter Medical Research Institute and University of Newcastle, Newcastle 2305, Australia
- Centre for Inflammation, Faculty of Science, School of Life Sciences, Centenary Institute and University of Technology Sydney, Sydney 2050, Australia
| | - Sukhwinder Singh Sohal
- Respiratory Translational Research Group, Department of Laboratory Medicine, School of Health Sciences, College of Health and Medicine, University of Tasmania, Launceston 7248, Australia
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12
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Shin JS, Niu M, Chen H, Grogan T, Lee JS, Liew EC, Umar S, Shin DH, Zhu Y, Hoftman NN. A novel negative pressure isolation device reduces aerosol exposure: A randomized controlled trial. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023; 49:101229. [PMID: 38621006 PMCID: PMC9986117 DOI: 10.1016/j.tacc.2023.101229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 03/08/2023]
Abstract
Background and aim The COVID-19 pandemic has led to a proliferation of intubation barriers designed to protect healthcare workers from infection. We developed the Suction-Assisted Local Aerosol Containment Chamber (SLACC) and tested it in the operating room. The primary objectives were to determine the ease and safety of airway management with SLACC, and to measure its efficacy of aerosol containment to determine if it significantly reduces exposure to health care workers. Methods In this randomized clinical trial, adult patients scheduled to undergo elective surgery with general endotracheal anesthesia were screened and informed consent obtained from those willing to participate. Patients were randomized to airway management either with or without the SLACC device. Patients inhaled nebulized saline before and during anesthesia induction to simulate the size and concentration of particles seen with severe symptomatic SARS-CoV-2 infection. Results 79 patients were enrolled and randomized. Particle number concentration (PNC) at the patients' and healthcare workers' locations were measured and compared between the SLACC vs. control groups during airway management. Ease and success of tracheal intubation were recorded for each patient. All intubations were successful and time to intubation was similar between the two groups. Healthcare workers were exposed to significantly lower particle number concentrations (#/cm3) during airway management when SLACC was utilized vs. control. The particle count outside SLACC was reduced by 97% compared to that inside the device. Conclusions The SLACC device does not interfere with airway management and significantly reduces healthcare worker exposure to aerosolized particles during airway management.
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Affiliation(s)
- John S Shin
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Muchuan Niu
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Haoxuan Chen
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Tristan Grogan
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Jason S Lee
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Elaine C Liew
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Soban Umar
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Dong Ho Shin
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Yifang Zhu
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Nir N Hoftman
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
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13
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Groma V, Kugler S, Farkas Á, Füri P, Madas B, Nagy A, Erdélyi T, Horváth A, Müller V, Szántó-Egész R, Micsinai A, Gálffy G, Osán J. Size distribution and relationship of airborne SARS-CoV-2 RNA to indoor aerosol in hospital ward environments. Sci Rep 2023; 13:3566. [PMID: 36864124 PMCID: PMC9980870 DOI: 10.1038/s41598-023-30702-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/28/2023] [Indexed: 03/04/2023] Open
Abstract
Aerosol particles proved to play a key role in airborne transmission of SARS-CoV-2 viruses. Therefore, their size-fractionated collection and analysis is invaluable. However, aerosol sampling in COVID departments is not straightforward, especially in the sub-500-nm size range. In this study, particle number concentrations were measured with high temporal resolution using an optical particle counter, and several 8 h daytime sample sets were collected simultaneously on gelatin filters with cascade impactors in two different hospital wards during both alpha and delta variants of concern periods. Due to the large number (152) of size-fractionated samples, SARS-CoV-2 RNA copies could be statistically analyzed over a wide range of aerosol particle diameters (70-10 µm). Our results revealed that SARS-CoV-2 RNA is most likely to exist in particles with 0.5-4 µm aerodynamic diameter, but also in ultrafine particles. Correlation analysis of particulate matter (PM) and RNA copies highlighted the importance of indoor medical activity. It was found that the daily maximum increment of PM mass concentration correlated the most with the number concentration of SARS-CoV-2 RNA in the corresponding size fractions. Our results suggest that particle resuspension from surrounding surfaces is an important source of SARS-CoV-2 RNA present in the air of hospital rooms.
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Affiliation(s)
- V Groma
- Environmental Physics Department, Centre for Energy Research, Budapest, 1121, Hungary
| | - Sz Kugler
- Environmental Physics Department, Centre for Energy Research, Budapest, 1121, Hungary
| | - Á Farkas
- Environmental Physics Department, Centre for Energy Research, Budapest, 1121, Hungary
| | - P Füri
- Environmental Physics Department, Centre for Energy Research, Budapest, 1121, Hungary
| | - B Madas
- Environmental Physics Department, Centre for Energy Research, Budapest, 1121, Hungary
| | - A Nagy
- Department of Applied and Nonlinear Optics, Wigner Research Centre for Physics, Budapest, 1121, Hungary
| | - T Erdélyi
- Department of Pulmonology, Semmelweis University, Budapest, 1085, Hungary
| | - A Horváth
- Department of Pulmonology, Semmelweis University, Budapest, 1085, Hungary
- Pest County Pulmonology Hospital, Törökbálint, 2045, Hungary
| | - V Müller
- Department of Pulmonology, Semmelweis University, Budapest, 1085, Hungary
| | | | | | - G Gálffy
- Pest County Pulmonology Hospital, Törökbálint, 2045, Hungary
| | - J Osán
- Environmental Physics Department, Centre for Energy Research, Budapest, 1121, Hungary.
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14
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Richter WR, Sunderman MM, Schaeufele DJ, Willenberg Z, Ratliff K, Calfee MW, Oudejans L. Evaluation of steam heat as a decontamination approach for SARS-CoV-2 when applied to common transit-related materials. J Appl Microbiol 2023; 134:lxad053. [PMID: 36906281 PMCID: PMC10257936 DOI: 10.1093/jambio/lxad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/31/2023] [Accepted: 03/10/2023] [Indexed: 03/13/2023]
Abstract
AIMS The purpose of this study was to evaluate the efficacy of steam heat for inactivation of SARS-CoV-2 when applied to materials common in mass transit installations. METHODS AND RESULTS SARS CoV-2 (USA-WA1/2020) was resuspended in either cell culture media or synthetic saliva, inoculated (∼1 × 106 TCID50) onto porous and nonporous materials and subjected to steam inactivation efficacy tests as either wet or dried droplets. The inoculated test materials were exposed to steam heat ranging from 70°C to 90°C. The amount of infectious SARS-CoV-2 remaining after various exposure durations ranging from 1 to 60 s was assessed. Higher steam heat application resulted in higher inactivation rates at short contact times. Steam applied at 1-inch distance (∼90°C at the surface) resulted in complete inactivation for dry inoculum within 2 s of exposure (excluding two outliers of 19 test samples at the 5-s duration) and within 2-30 s of exposure for wet droplets. Increasing the distance to 2 inches (∼70°C) also increased the exposure time required to achieve complete inactivation to 15 or 30 s for materials inoculated with saliva or cell culture media, respectively. CONCLUSIONS Steam heat can provide high levels of decontamination (>3 log reduction) for transit-related materials contaminated with SARS-CoV-2 using a commercially available steam generator with a manageable exposure time of 2-5 s.
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Affiliation(s)
| | | | | | | | - Katherine Ratliff
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Solutions and Emergency Response, Research Triangle Park, NC 27711, United States
| | - M. Worth Calfee
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Solutions and Emergency Response, Research Triangle Park, NC 27711, United States
| | - Lukas Oudejans
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Solutions and Emergency Response, Research Triangle Park, NC 27711, United States
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15
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Sultan S. Gastrointestinal Endoscopy in Patients with Coronavirus Disease 2019: Indications, Findings, and Safety. Gastroenterol Clin North Am 2023; 52:157-172. [PMID: 36813423 PMCID: PMC9678816 DOI: 10.1016/j.gtc.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has changed the practice of gastroenterology and how we perform endoscopy. As with any new or emerging pathogen, early in the pandemic, there was limited evidence and understanding of disease transmission, limited testing capability, and resource constraints, especially availability of personal protective equipment (PPE). As the COVID-19 pandemic progressed, enhanced protocols with particular emphasis on assessing the risk status of patients and proper use of PPE have been incorporated into routine patient care. The COVID-19 pandemic has taught us important lessons for the future of gastroenterology and endoscopy.
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Affiliation(s)
- Shahnaz Sultan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 420 Delaware Street Southeast, MMC 36, Minneapolis, MN 55455, USA.
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16
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Schumm B, Heiber M, Grätz F, Stabile L, Buonanno G, Schönfelder M, Hain R, Kähler CJ, Wackerhage H. Respiratory aerosol particle emission and simulated infection risk is greater during indoor endurance than resistance exercise. Proc Natl Acad Sci U S A 2023; 120:e2220882120. [PMID: 36802418 PMCID: PMC9992860 DOI: 10.1073/pnas.2220882120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/06/2023] [Indexed: 02/23/2023] Open
Abstract
Pathogens such as severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), influenza, and rhinoviruses are transmitted by airborne aerosol respiratory particles that are exhaled by infectious subjects. We have previously reported that the emission of aerosol particles increases on average 132-fold from rest to maximal endurance exercise. The aims of this study are to first measure aerosol particle emission during an isokinetic resistance exercise at 80% of the maximal voluntary contraction until exhaustion, second to compare aerosol particle emission during a typical spinning class session versus a three-set resistance training session. Finally, we then used this data to calculate the risk of infection during endurance and resistance exercise sessions with different mitigation strategies. During a set of isokinetic resistance exercise, aerosol particle emission increased 10-fold from 5,400 ± 1,200 particles/min at rest to 59,000 ± 69,900 particles/min during a set of resistance exercise. We found that aerosol particle emission per minute is on average 4.9-times lower during a resistance training session than during a spinning class. Using this data, we determined that the simulated infection risk increase during an endurance exercise session was sixfold higher than during a resistance exercise session when assuming one infected participant in the class. Collectively, this data helps to select mitigation measures for indoor resistance and endurance exercise classes at times where the risk of aerosol-transmitted infectious disease with severe outcomes is high.
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Affiliation(s)
- Benedikt Schumm
- Institute of Fluid Mechanics and Aerodynamics, Universität der Bundeswehr München, 85577Neubiberg, Germany
| | - Marie Heiber
- Institute of Sport Science, Universität der Bundeswehr München, 85577Neubiberg, Germany
- Associate Professorship of Exercise Biology, Technische Universität München, 80809Munich, Germany
| | - Felix Grätz
- Associate Professorship of Exercise Biology, Technische Universität München, 80809Munich, Germany
| | - Luca Stabile
- University of Cassino and Southern Lazio, Department of Civil and Mechanical Engineering, 03043Cassino, Italy
| | - Giorgio Buonanno
- University of Cassino and Southern Lazio, Department of Civil and Mechanical Engineering, 03043Cassino, Italy
- Queensland University of Technology, 4000QLD, Australia
| | - Martin Schönfelder
- Associate Professorship of Exercise Biology, Technische Universität München, 80809Munich, Germany
| | - Rainer Hain
- Institute of Fluid Mechanics and Aerodynamics, Universität der Bundeswehr München, 85577Neubiberg, Germany
| | - Christian J. Kähler
- Institute of Fluid Mechanics and Aerodynamics, Universität der Bundeswehr München, 85577Neubiberg, Germany
| | - Henning Wackerhage
- Associate Professorship of Exercise Biology, Technische Universität München, 80809Munich, Germany
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17
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Healthcare workers' infection risk perceptions of aerosol-generating procedures and affective response. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e29. [PMID: 36865705 PMCID: PMC9972538 DOI: 10.1017/ash.2022.276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 02/17/2023]
Abstract
Objective To understand healthcare worker (HCW) perceptions of infection risk associated with aerosol-generating procedures (AGPs) and their affective response to performing AGPs. Design Systematic review. Methods Systematic searches of PubMed, CINHAL Plus, and Scopus were conducted using combinations of selected keywords and synonyms. To reduce bias, titles and abstracts were screened for eligibility by 2 independent reviewers. Also, 2 independent reviewers extracted data from each eligible record. Discrepancies were discussed until consensus was reached. Results In total, 16 reports from across the globe were included in this review. Findings suggest that AGPs are generally perceived to place HCWs at high risk of becoming infected with respiratory pathogens and that this perception stimulates a negative affective response and hesitancy to participate in the procedures. Conclusions AGP risk perception are complex and context dependent but have important influences on HCW infection control practices, decision to participate in AGPs, emotional welfare, and workplace satisfaction. New and unfamiliar hazards paired with uncertainty lead to fear and anxiety about personal and others' safety. These fears may create a psychological burden conducive to burnout. Empirical research is needed to thoroughly understand the interplay between HCW risk perceptions of distinct AGPs, their affective responses to conducting these procedures under various conditions, and their resulting decision to participate in these procedures. Results from such studies are essential for advancing clinical practice; they point to methods for mitigating provider distress and better recommendations for when and how to conduct AGPs.
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18
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Alsaad H, Schälte G, Schneeweiß M, Becher L, Pollack M, Gena AW, Schweiker M, Hartmann M, Voelker C, Rossaint R, Irrgang M. The Spread of Exhaled Air and Aerosols during Physical Exercise. J Clin Med 2023; 12:jcm12041300. [PMID: 36835835 PMCID: PMC9961458 DOI: 10.3390/jcm12041300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023] Open
Abstract
Physical exercise demonstrates a special case of aerosol emission due to its associated elevated breathing rate. This can lead to a faster spread of airborne viruses and respiratory diseases. Therefore, this study investigates cross-infection risk during training. Twelve human subjects exercised on a cycle ergometer under three mask scenarios: no mask, surgical mask, and FFP2 mask. The emitted aerosols were measured in a grey room with a measurement setup equipped with an optical particle sensor. The spread of expired air was qualitatively and quantitatively assessed using schlieren imaging. Moreover, user satisfaction surveys were conducted to evaluate the comfort of wearing face masks during training. The results indicated that both surgical and FFP2 masks significantly reduced particles emission with a reduction efficiency of 87.1% and 91.3% of all particle sizes, respectively. However, compared to surgical masks, FFP2 masks provided a nearly tenfold greater reduction of the particle size range with long residence time in the air (0.3-0.5 μm). Furthermore, the investigated masks reduced exhalation spreading distances to less than 0.15 m and 0.1 m in the case of the surgical mask and FFP2 mask, respectively. User satisfaction solely differed with respect to perceived dyspnea between no mask and FFP2 mask conditions.
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Affiliation(s)
- Hayder Alsaad
- Department of Building Physics, Faculty of Civil Engineering, Bauhaus-University Weimar, 99423 Weimar, Germany
- Correspondence: (H.A.); (M.I.)
| | - Gereon Schälte
- Department of Anesthesiology, Medical Faculty, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Mario Schneeweiß
- Department of Building Physics, Faculty of Civil Engineering, Bauhaus-University Weimar, 99423 Weimar, Germany
| | - Lia Becher
- Department of Building Physics, Faculty of Civil Engineering, Bauhaus-University Weimar, 99423 Weimar, Germany
| | - Moritz Pollack
- Department of Building Physics, Faculty of Civil Engineering, Bauhaus-University Weimar, 99423 Weimar, Germany
| | - Amayu Wakoya Gena
- Department of Building Physics, Faculty of Civil Engineering, Bauhaus-University Weimar, 99423 Weimar, Germany
| | - Marcel Schweiker
- Healthy Living Spaces Lab, Institute for Occupational, Social, and Environmental Medicine, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Maria Hartmann
- Department of Building Physics, Faculty of Civil Engineering, Bauhaus-University Weimar, 99423 Weimar, Germany
| | - Conrad Voelker
- Department of Building Physics, Faculty of Civil Engineering, Bauhaus-University Weimar, 99423 Weimar, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, Medical Faculty, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Matthias Irrgang
- Department of Anesthesiology, Medical Faculty, University Hospital RWTH Aachen, 52074 Aachen, Germany
- Correspondence: (H.A.); (M.I.)
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19
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Harrison S, Davies E, Shelton C. Aerosol-generating procedures: research, guidance and implementation. Anaesthesia 2023; 78:150-154. [PMID: 36196792 DOI: 10.1111/anae.15878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 01/11/2023]
Affiliation(s)
- S Harrison
- North West School of Anaesthesia, Manchester, UK
| | - E Davies
- North West School of Anaesthesia, Manchester, UK
| | - C Shelton
- Department of Anaesthesia, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Lancaster Medical School, Lancaster University, Lancaster, Lancashire, UK
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20
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Song SH, Choi SH, Park HR, Jeon SY, Kim SH. Risk of Bacterial Exposure to the Anesthesiologist's Face During Intubation and Extubation. Infect Drug Resist 2023; 16:2433-2439. [PMID: 37138835 PMCID: PMC10149769 DOI: 10.2147/idr.s405537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/15/2023] [Indexed: 05/05/2023] Open
Abstract
Introduction Anesthesiologists are exposed to the risk of infection from various secretions or droplets from the respiratory tract of patients. We aimed to determine bacterial exposure to anesthesiologists' faces during endotracheal intubation and extubation. Methods Six resident anesthesiologists performed 66 intubation and 66 extubation procedures in patients undergoing elective otorhinolaryngology surgeries. Sampling was performed by swabbing the face shields twice in an overlapping slalom pattern, before and after each procedure. Samples for pre-intubation and pre-extubation were collected immediately after wearing the face shield at the time of anesthesia induction and at the end of the surgery, respectively. Post-intubation samples were collected after the injection of anesthetic drugs, positive pressure mask ventilation, endotracheal intubation, and confirmation of intubation success. Post-extubation samples were collected after endotracheal tube suction, oral suction, extubation, and confirmation of spontaneous breathing and stable vital signs. All swabs were cultured for 48 h, and bacterial growth was confirmed by colony forming unit (CFU) count. Results There was no bacterial growth in either pre- or post-intubation bacterial cultures. In contrast, while there was no bacterial growth in pre-extubation samples, 15.2% of post-extubation samples were CFU+ (0/66 [0%] vs 10/66 [15.2%], p=0.001). All the CFU+ samples belonged to 47 patients with post-extubation coughing, and the CFU count was correlated with the number of coughing episodes during the process of extubation (P < 0.01, correlation coefficient= 0.403). Conclusion The current study shows the actual chance of bacterial exposure to the anesthesiologist's face during the patient awakening process after general anesthesia. Given the correlation between the CFU count and the number of coughing episodes, we recommend anesthesiologists to use appropriate facial protection equipment during this procedure.
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Affiliation(s)
- Sei Han Song
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hae Ri Park
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Yeon Jeon
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Correspondence: Seung Hyun Kim, Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea, Tel +82-2-2224-1055, Fax +82-2-2227-7897, Email
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21
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McGrath JA, O’Sullivan A, Joyce M, Byrne MA, Li J, Fink JB, MacLoughlin R. In vitro model for investigating aerosol dispersion in a simulated COVID-19 patient during high-flow nasal cannula treatment. Front Med (Lausanne) 2022; 9:1002659. [PMID: 36530866 PMCID: PMC9751314 DOI: 10.3389/fmed.2022.1002659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/14/2022] [Indexed: 08/05/2023] Open
Abstract
The use of high-flow nasal cannula in the treatment of COVID-19 infected patients has proven to be a valuable treatment option to improve oxygenation. Early in the pandemic, there were concerns for the degree of risk of disease transmission to health care workers utilizing these treatments that are considered aerosol generating procedures. This study developed an in vitro model to examine the release of simulated patient-derived bioaerosol with and without high-flow nasal cannula at gas flow rates of 30 and 50 L/min. Aerosol dispersion was evaluated at 30 and 90 cm distances. Reduction of transmission risk was assessed using a surgical facemask on the manikin. Results indicated that the use of a facemask facilitated a 94-95% reduction in exhaled aerosol concentration at 30 cm and 22-60% reduction for 90 cm distance across both gas flow rates. This bench study confirms that this in vitro model can be used as a tool to assess the risk of disease transmission during aerosol generating procedures in a simulated patient and to test factors to mitigate the risk.
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Affiliation(s)
- James A. McGrath
- Department of Physics, School of Natural Science, Ryan Institute’s Centre for Climate & Air Pollution Studies, University of Galway, Galway, Ireland
| | - Andrew O’Sullivan
- Research & Development, Science & Emerging Technologies, Aerogen Limited, Galway, Ireland
| | - Mary Joyce
- Research & Development, Science & Emerging Technologies, Aerogen Limited, Galway, Ireland
| | - Miriam A. Byrne
- Department of Physics, School of Natural Science, Ryan Institute’s Centre for Climate & Air Pollution Studies, University of Galway, Galway, Ireland
| | - Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, IL, United States
| | - James B. Fink
- Aerogen Pharma Corporation, San Mateo, CA, United States
| | - Ronan MacLoughlin
- Research & Development, Science & Emerging Technologies, Aerogen Limited, Galway, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
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22
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Dabisch PA, Sanjak JS, Boydston JA, Yeager J, Herzog A, Biryukov J, Beck K, Do D, Seman BG, Green B, Bohannon JK, Holland B, Miller D, Ammons T, Freeburger D, Miller S, Jenkins T, Rippeon S, Miller J, Clarke D, Manan E, Patty A, Rhodes K, Sweeney T, Winpigler M, Altamura LA, Zimmerman H, Hail AS, Wahl V, Hevey M. Comparison of Dose-Response Relationships for Two Isolates of SARS-CoV-2 in a Nonhuman Primate Model of Inhalational COVID-19. J Aerosol Med Pulm Drug Deliv 2022; 35:296-306. [PMID: 36318785 PMCID: PMC9807281 DOI: 10.1089/jamp.2022.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/20/2022] [Indexed: 12/05/2022] Open
Abstract
Background: As the COVID-19 pandemic has progressed, numerous variants of SARS-CoV-2 have arisen, with several displaying increased transmissibility. Methods: The present study compared dose-response relationships and disease presentation in nonhuman primates infected with aerosols containing an isolate of the Gamma variant of SARS-CoV-2 to the results of our previous study with the earlier WA-1 isolate of SARS-CoV-2. Results: Disease in Gamma-infected animals was mild, characterized by dose-dependent fever and oronasal shedding of virus. Differences were observed in shedding in the upper respiratory tract between Gamma- and WA-1-infected animals that have the potential to influence disease transmission. Specifically, the estimated median doses for shedding of viral RNA or infectious virus in nasal swabs were approximately 10-fold lower for the Gamma variant than the WA-1 isolate. Given that the median doses for fever were similar, this suggests that there is a greater difference between the median doses for viral shedding and fever for Gamma than for WA-1 and potentially an increased range of doses for Gamma over which asymptomatic shedding and disease transmission are possible. Conclusions: These results complement those of previous studies, which suggested that differences in exposure dose may help to explain the range of clinical disease presentations observed in individuals with COVID-19, highlighting the importance of public health measures designed to limit exposure dose, such as masking and social distancing. The dose-response data provided by this study are important to inform disease transmission and hazard modeling, as well as to inform dose selection in future studies examining the efficacy of therapeutics and vaccines in animal models of inhalational COVID-19.
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Affiliation(s)
- Paul A. Dabisch
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Jaleal S. Sanjak
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland, USA
| | - Jeremy A. Boydston
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - John Yeager
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | | | - Jennifer Biryukov
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Katie Beck
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Danh Do
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Brittany G. Seman
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Brian Green
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Jordan K. Bohannon
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Brian Holland
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - David Miller
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Taylor Ammons
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Denise Freeburger
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Susan Miller
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Tammy Jenkins
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Sherry Rippeon
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - James Miller
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - David Clarke
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Emmanuel Manan
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Ashley Patty
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Kim Rhodes
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Tina Sweeney
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Michael Winpigler
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Louis A. Altamura
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Heather Zimmerman
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Alec S. Hail
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Victoria Wahl
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
| | - Michael Hevey
- National Biodefense Analysis and Countermeasures Center, Operated by Battelle National Biodefense Institute, U.S. Department of Homeland Security, Frederick, Maryland, USA
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Andrés M, García MC, Fajardo A, Grau L, Pagespetit L, Plasencia V, Martínez I, Abadía C, Sanahuja A, Bella F. Nosocomial outbreak of COVID-19 in an internal medicine ward: Probable airborne transmission. Rev Clin Esp 2022; 222:578-583. [PMID: 35798645 PMCID: PMC9239913 DOI: 10.1016/j.rceng.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/09/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite the increasing evidence supporting the importance of airborne transmission in SARS-CoV-2 infection, it has not been considered relevant in the vast majority of reported nosocomial outbreaks of COVID-19. The aim of this study is to describe a nosocomial outbreak of SARS-CoV-2 infection whose features suggest that aerosol transmission had an important role. METHODS This is a descriptive analysis of a nosocomial outbreak of SARS-CoV-2 infection in an internal medicine ward that occurred in December 2020. All cases were confirmed by a positive PCR test for SARS-CoV-2. RESULTS From December 5 to December 17, 21 patients and 44 healthcare workers (HCWs) developed a nosocomial SARS-CoV-2 infection. Fifty-one of the 65 cases (78.5%) were diagnosed between December 6 and 9. The attack rate in patients was 80.8%. Among HCWs, the attack rate was higher in those who had worked at least one full working day in the ward (56.3%) than in those who had occasionally been in the ward (25.8%; p = 0.005). Three days before the first positive case was detected, two extractor fans were found to be defective, affecting the ventilation of three rooms. Sixteen cases were asymptomatic, 48 cases had non-severe symptoms, and 2 cases required admission to the intensive care unit. All patients eventually recovered. CONCLUSION The high attack rate, the explosive nature of the outbreak, and the coincidence in time with the breakdown in air extractors in some rooms of the ward suggest that airborne transmission played a key role in the development of the outbreak.
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Affiliation(s)
- M Andrés
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital de Terrassa (Consorci Sanitari de Terrassa), Terrassa (Barcelona), Spain.
| | - M-C García
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital de Terrassa (Consorci Sanitari de Terrassa), Terrassa (Barcelona), Spain
| | - A Fajardo
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital de Terrassa (Consorci Sanitari de Terrassa), Terrassa (Barcelona), Spain
| | - L Grau
- Equipo de Control de Infecciones, Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital de Terrassa (Consorci Sanitari de Terrassa), Terrassa (Barcelona), Spain
| | - L Pagespetit
- Equipo de Control de Infecciones, Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital de Terrassa (Consorci Sanitari de Terrassa), Terrassa (Barcelona), Spain
| | - V Plasencia
- Laboratorio de Microbiología, CATLAB, Viladecavalls (Barcelona), Spain
| | - I Martínez
- Servicio de Prevención de Riesgos Laborales, Hospital de Terrassa (Consorci Sanitari de Terrassa), Terrassa (Barcelona), Spain
| | - C Abadía
- Servicio de Salud Laboral, Hospital de Terrassa (Consorci Sanitari de Terrassa), Terrassa (Barcelona), Spain
| | - A Sanahuja
- Departamento de Recursos Físicos, Hospital de Terrassa (Consorci Sanitari de Terrassa), Terrassa (Barcelona), Spain
| | - F Bella
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital de Terrassa (Consorci Sanitari de Terrassa), Terrassa (Barcelona), Spain
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Silvers A, Brewster DJ, Ford A, Licina A, Andrews C, Adams M. Re-evaluating our language when reducing risk of SARS-CoV-2 transmission to healthcare workers: Time to rethink the term, “aerosol-generating procedures”. Virol J 2022; 19:189. [PMCID: PMC9672604 DOI: 10.1186/s12985-022-01910-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/22/2022] [Indexed: 11/19/2022] Open
Abstract
AbstractThe term, "aerosol-generating procedures” (AGPs), was proposed during the prior SARS-CoV-1 epidemic in order to maximise healthcare worker and patient protection. The concept of AGPs has since expanded to include routine therapeutic processes such as various modes of oxygen delivery and non-invasive ventilation modalities. Evidence gained during the SARS-CoV-2 pandemic has brought into question the concept of AGPs with regard to intubation, airway management, non-invasive ventilation and high flow nasal oxygen delivery. Although encounters where these procedures occur may still be associated with increased risk of infectious transmission, this is a function of the clinical context and not because the procedure itself is aerosol-generating.
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Alonso JM, Lipman J, Shekar K. A novel barrier device and method for protection against airborne pathogens during endotracheal intubation. Eur J Anaesthesiol 2022; 39:900-903. [PMID: 36093872 PMCID: PMC9553218 DOI: 10.1097/eja.0000000000001731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Julio M Alonso
- From the Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital (JMA, KS), University of Queensland, Brisbane (JMA, JL), Jamieson Trauma Institute and Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (JL), Nimes University Hospital, University of Montpellier, Nimes, France (JL), Queensland University of Technology (KS), University of Queensland, Brisbane (KS) and Bond University, Gold Coast, Queensland, Australia (KS)
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26
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Gohli J, Brantsæter AB, Bøifot KO, Grub C, Granerud BK, Holter JC, Riise AMD, Smedholen MF, Dybwad M. SARS-CoV-2 in the Air Surrounding Patients during Nebulizer Therapy. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2022; 2022:9297974. [PMID: 36213437 PMCID: PMC9536972 DOI: 10.1155/2022/9297974] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/05/2022] [Accepted: 08/29/2022] [Indexed: 11/19/2022]
Abstract
Nebulizer therapy is commonly used for patients with obstructive pulmonary disease or acute pulmonary infections with signs of obstruction. It is considered a "potential aerosol-generating procedure," and the risk of disease transmission to health care workers is uncertain. The aim of this pilot study was to assess whether nebulizer therapy in hospitalized COVID-19 patients is associated with increased dispersion of SARS-CoV-2. Air samples collected prior to and during nebulizer therapy were analyzed by RT-PCR and cell culture. Total aerosol particle concentrations were also quantified. Of 13 patients, seven had quantifiable virus in oropharynx samples, and only two had RT-PCR positive air samples. For both these patients, air samples collected during nebulizer therapy had higher SARS-CoV-2 RNA concentrations compared to control air samples. Also, for particle sizes 0.3-5 µm, particle concentrations were significantly higher during nebulizer therapy than in controls. We were unable to cultivate virus from any of the RT-PCR positive air samples, and it is therefore unknown if the detected virus were replication-competent; however, the significant increase in smaller particles, which can remain airborne for extended periods of time, and increased viral RNA concentrations during treatment may indicate that nebulizer therapy is associated with increased risk of SARS-CoV-2 transmission.
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Affiliation(s)
- Jostein Gohli
- Norwegian Defence Research Establishment, P. O. Box 25, No. 2027 Kjeller, Oslo, Norway
| | - Arne Broch Brantsæter
- Department of Infectious Diseases, Oslo University Hospital, P. O. Box 4956, Nydalen, No. 0424, Oslo, Norway
- Norwegian National Unit for CBRNE Medicine, Oslo University Hospital, P. O. Box 4956, Nydalen, No. 0424, Oslo, Norway
| | - Kari Oline Bøifot
- Norwegian Defence Research Establishment, P. O. Box 25, No. 2027 Kjeller, Oslo, Norway
- Department of Analytics, Environmental & Forensic Sciences, King's College London, 150 Stamford Street, London SE1 9NH, UK
| | - Carola Grub
- Institute of Microbiology, Norwegian Armed Forces Joint Medical Services, P. O. Box 25, No. 2027, Kjeller, Oslo, Norway
| | - Beathe Kiland Granerud
- Department of Microbiology, Oslo University Hospital, P. O. Box 4950, Blindern, No. 0424, Oslo, Norway
- Department of Nursing, Health and Laboratory Science, University College of Østfold, P. O. Box 700, No. 1757, Halden, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, P. O. Box 1171, Blindern, No. 0318, Oslo, Norway
| | - Jan Cato Holter
- Department of Microbiology, Oslo University Hospital, P. O. Box 4950, Blindern, No. 0424, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, P. O. Box 1171, Blindern, No. 0318, Oslo, Norway
| | - Anne Margarita Dyrhol Riise
- Department of Infectious Diseases, Oslo University Hospital, P. O. Box 4956, Nydalen, No. 0424, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, P. O. Box 1171, Blindern, No. 0318, Oslo, Norway
| | | | - Marius Dybwad
- Norwegian Defence Research Establishment, P. O. Box 25, No. 2027 Kjeller, Oslo, Norway
- Department of Analytics, Environmental & Forensic Sciences, King's College London, 150 Stamford Street, London SE1 9NH, UK
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Shrimpton AJ, Pickering AE. Aerosols: time to clear the air? Anaesthesia 2022; 77:1193-1196. [DOI: 10.1111/anae.15864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/30/2022]
Affiliation(s)
- A. J. Shrimpton
- Anaesthesia, Pain and Critical Care Sciences, School of Physiology, Pharmacology and Neuroscience University of Bristol UK
| | - A. E. Pickering
- Anaesthesia, Pain and Critical Care Sciences, School of Physiology, Pharmacology and Neuroscience University of Bristol UK
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Joan TV, Kristiyan SA, Ernest SL, Nuria TP, Herme GB, Josep MB. Efficiency and sensitivity optimization of a protocol to quantify indoor airborne SARS-CoV-2 levels. J Hosp Infect 2022; 130:44-51. [PMID: 36100140 PMCID: PMC9465472 DOI: 10.1016/j.jhin.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 11/29/2022]
Abstract
Background Development of methodologies to quantify airborne micro-organisms is needed for the prevention and control of infections. It is difficult to conclude which is the most efficient and sensitive strategy to assess airborne SARS-CoV-2 RNA levels due to the disparity of results reported in clinical settings. Aim To improve our previously reported protocol of measuring SARS-CoV-2 RNA levels, which was based on bioaerosol collection with a liquid impinger and RNA quantification with droplet digital polymerase chain reaction (ddPCR). Methods Air samples were collected in COVID-19 patient rooms to assess efficiency and/or sensitivity of different air samplers, liquid collection media, and reverse transcriptases (RT). Findings Mineral oil retains airborne RNA better than does hydrophilic media without impairing integrity. SARS-CoV-2 ORF1ab target was detected in 80% of the air samples using BioSampler with mineral oil. No significant differences in effectiveness were obtained with MD8 sampler equipped with gelatine membrane filters, but the SARS-CoV-2 copies/m3 air obtained with the latter were lower (28.4 ± 6.1 vs 9 ± 1.7). SuperScript II RT allows the detection of a single SARS-CoV-2 genome RNA molecule by ddPCR with high efficiency. This was the only RT that allowed the detection of SARS-CoV-2 N1 target in air samples. Conclusion The collection efficiency and detection sensivity of a protocol to quantify SARS-CoV-2 RNA levels in indoor air has been improved in the present study. Such optimization is important to improve our understanding of the microbiological safety of indoor air.
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Affiliation(s)
- Truyols-Vives Joan
- Molecular Biology and One Health Research Group (MolONE), Universitat de Les Illes Balears (UIB), Palma, Spain
| | | | - Sala-Llinàs Ernest
- Molecular Biology and One Health Research Group (MolONE), Universitat de Les Illes Balears (UIB), Palma, Spain; Health Research Institute of the Balearic Islands (IdISBa), Balearic Islands, Spain; Department of Pulmonary Medicine, Hospital Universitari Son Espases (HUSE), Balearic Islands, Spain; Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Toledo-Pons Nuria
- Health Research Institute of the Balearic Islands (IdISBa), Balearic Islands, Spain; Department of Pulmonary Medicine, Hospital Universitari Son Espases (HUSE), Balearic Islands, Spain
| | - G Baldoví Herme
- Department of Chemistry, Universitat Politècnica de València (UPV)
| | - Mercader-Barceló Josep
- Molecular Biology and One Health Research Group (MolONE), Universitat de Les Illes Balears (UIB), Palma, Spain; Health Research Institute of the Balearic Islands (IdISBa), Balearic Islands, Spain.
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Shrimpton AJ, Osborne CED, Brown JM, Cook TM, Penfold C, Rooshenas L, Pickering AE. Anaesthetists' current practice and perceptions of aerosol-generating procedures: a mixed-methods study. Anaesthesia 2022; 77:959-970. [PMID: 35864419 PMCID: PMC9543704 DOI: 10.1111/anae.15803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2022] [Indexed: 01/11/2023]
Abstract
The evidence base surrounding the transmission risk of 'aerosol-generating procedures' has evolved primarily through quantification of aerosol concentrations during clinical practice. Consequently, infection prevention and control guidelines are undergoing continual reassessment. This mixed-methods study aimed to explore the perceptions of practicing anaesthetists regarding aerosol-generating procedures. An online survey was distributed to the Membership Engagement Group of the Royal College of Anaesthetists during November 2021. The survey included five clinical scenarios to identify the personal approach of respondents to precautions, their hospital's policies and the associated impact on healthcare provision. A purposive sample was selected for interviews to explore the reasoning behind their perceptions and behaviours in greater depth. A total of 333 survey responses were analysed quantitatively. Transcripts from 18 interviews were coded and analysed thematically. The sample was broadly representative of the UK anaesthetic workforce. Most respondents and their hospitals were aware of, supported and adhered to UK guidance. However, there were examples of substantial divergence from these guidelines at both individual and hospital level. For example, 40 (12%) requested respiratory protective equipment and 63 (20%) worked in hospitals that required it to be worn whilst performing tracheal intubation in SARS-CoV-2 negative patients. Additionally, 173 (52%) wore respiratory protective equipment whilst inserting supraglottic airway devices. Regarding the use of respiratory protective equipment and fallow times in the operating theatre: 305 (92%) perceived reduced efficiency; 376 (83%) perceived a negative impact on teamworking; 201 (64%) were worried about environmental impact; and 255 (77%) reported significant problems with communication. However, 269 (63%) felt the negative impacts of respiratory protection equipment were appropriately balanced against the risks of SARS-CoV-2 transmission. Attitudes were polarised about the prospect of moving away from using respiratory protective equipment. Participants' perceived risk from COVID-19 correlated with concern regarding stepdown (Spearman's test, R = 0.36, p < 0.001). Attitudes towards aerosol-generating procedures and the need for respiratory protective equipment are evolving and this information can be used to inform strategies to facilitate successful adoption of revised guidelines.
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Affiliation(s)
- A. J. Shrimpton
- Anaesthesia, Pain and Critical Care Sciences, School of Physiology, Pharmacology and NeuroscienceUniversity of BristolUK
| | - C. E. D. Osborne
- Anaesthesia, Pain and Critical Care Sciences, School of Physiology, Pharmacology and NeuroscienceUniversity of BristolUK
| | - J. M. Brown
- Department of Anaesthesia and Intensive Care MedicineNorth Bristol NHS TrustBristolUK
| | - T. M. Cook
- Department of Anaesthesia and Intensive Care MedicineRoyal United Hospital NHS TrustBathUK
| | - C. Penfold
- NIHR Bristol Biomedical Research CentreUniversity Hospitals Bristol and Weston NHS Foundation Trust and University of BristolUK
| | - L. Rooshenas
- Bristol Medical School, Bristol Population Health Science InstituteUniversity of BristolUK
| | - A. E. Pickering
- Anaesthesia, Pain and Critical Care Sciences, School of Physiology, Pharmacology and NeuroscienceUniversity of BristolUK
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30
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Borg BM, Osadnik C, Adam K, Chapman DG, Farrow CE, Glavas V, Hancock K, Lanteri CJ, Morris EG, Romeo N, Schneider‐Futschik EK, Selvadurai H. Pulmonary function testing during SARS-CoV-2: An ANZSRS/TSANZ position statement. Respirology 2022; 27:688-719. [PMID: 35981737 PMCID: PMC9539179 DOI: 10.1111/resp.14340] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022]
Abstract
The Thoracic Society of Australia and New Zealand (TSANZ) and the Australian and New Zealand Society of Respiratory Science (ANZSRS) commissioned a joint position paper on pulmonary function testing during coronavirus disease 2019 (COVID-19) in July 2021. A working group was formed via an expression of interest to members of both organizations and commenced work in September 2021. A rapid review of the literature was undertaken, with a 'best evidence synthesis' approach taken to answer the research questions formed. This allowed the working group to accept findings of prior relevant reviews or societal document where appropriate. The advice provided is for providers of pulmonary function tests across all settings. The advice is intended to supplement local infection prevention and state, territory or national directives. The working group's key messages reflect a precautionary approach to protect the safety of both healthcare workers (HCWs) and patients in a rapidly changing environment. The decision on strategies employed may vary depending on local transmission and practice environment. The advice is likely to require review as evidence grows and the COVID-19 pandemic evolves. While this position statement was contextualized specifically to the COVID-19 pandemic, the working group strongly advocates that any changes to clinical/laboratory practice, made in the interest of optimizing the safety and well-being of HCWs and patients involved in pulmonary function testing, are carefully considered in light of their potential for ongoing use to reduce transmission of other droplet and/or aerosol borne diseases.
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Affiliation(s)
- Brigitte M. Borg
- Respiratory MedicineThe AlfredMelbourneVictoriaAustralia
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Christian Osadnik
- Department of PhysiotherapyMonash UniversityFrankstonVictoriaAustralia
- Monash Lung Sleep Allergy & ImmunologyMonash HealthClaytonVictoriaAustralia
| | - Keith Adam
- Sonic HealthPlusOsborne ParkWestern AustraliaAustralia
| | - David G. Chapman
- Respiratory Investigation Unit, Department of Respiratory MedicineRoyal North Shore HospitalSt LeonardsNew South WalesAustralia
- Airway Physiology & Imaging Group, Woolcock Institute of Medical ResearchThe University of SydneyGlebeNew South WalesAustralia
- Discipline of Medical Science, School of Life Sciences, Faculty of ScienceUniversity of Technology SydneyUltimoNew South WalesAustralia
| | - Catherine E. Farrow
- Airway Physiology & Imaging Group, Woolcock Institute of Medical ResearchThe University of SydneyGlebeNew South WalesAustralia
- Respiratory Function Laboratory, Department of Respiratory and Sleep MedicineWestmead HospitalWestmeadNew South WalesAustralia
- Westmead Clinical School, Sydney Medical School, Faculty of Medicine and Health SciencesThe University of SydneySydneyNew South WalesAustralia
| | | | - Kerry Hancock
- Chandlers Hill SurgeryHappy ValleySouth AustraliaAustralia
| | - Celia J. Lanteri
- Department of Respiratory & Sleep MedicineAustin HealthHeidelbergVictoriaAustralia
- Institute for Breathing and SleepAustin HealthHeidelbergVictoriaAustralia
| | - Ewan G. Morris
- Department of Respiratory MedicineWaitematā District Health BoardAucklandNew Zealand
| | - Nicholas Romeo
- Department of Respiratory MedicineNorthern HealthEppingVictoriaAustralia
| | - Elena K. Schneider‐Futschik
- Cystic Fibrosis Pharmacology Laboratory, Department of Biochemistry & PharmacologyUniversity of MelbourneParkvilleVictoriaAustralia
- School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVictoriaAustralia
| | - Hiran Selvadurai
- Department of Respiratory MedicineThe Children's Hospital, Westmead, Sydney Childrens Hospital NetworkSydneyNSWAustralia
- Discipline of Child and Adolescent HealthSydney Medical School, The University of SydneySydneyNSWAustralia
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Thuresson S, Fraenkel CJ, Sasinovich S, Soldemyr J, Widell A, Medstrand P, Alsved M, Löndahl J. Airborne Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospitals: Effects of Aerosol-Generating Procedures, HEPA-Filtration Units, Patient Viral Load, and Physical Distance. Clin Infect Dis 2022; 75:e89-e96. [PMID: 35226740 PMCID: PMC9383519 DOI: 10.1093/cid/ciac161] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Transmission of coronavirus disease 2019 (COVID-19) can occur through inhalation of fine droplets or aerosols containing infectious virus. The objective of this study was to identify situations, patient characteristics, environmental parameters, and aerosol-generating procedures (AGPs) associated with airborne severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. METHODS Air samples were collected near hospitalized COVID-19 patients and analyzed by RT-qPCR. Results were related to distance to the patient, most recent patient diagnostic PCR cycle threshold (Ct) value, room ventilation, and ongoing potential AGPs. RESULTS In total, 310 air samples were collected; of these, 26 (8%) were positive for SARS-CoV-2. Of the 231 samples from patient rooms, 22 (10%) were positive for SARS-CoV-2. Positive air samples were associated with a low patient Ct value (OR, 5.0 for Ct <25 vs >25; P = .01; 95% CI: 1.18-29.5) and a shorter physical distance to the patient (OR, 2.0 for every meter closer to the patient; P = .05; 95% CI: 1.0-3.8). A mobile HEPA-filtration unit in the room decreased the proportion of positive samples (OR, .3; P = .02; 95% CI: .12-.98). No association was observed between SARS-CoV-2-positive air samples and mechanical ventilation, high-flow nasal cannula, nebulizer treatment, or noninvasive ventilation. An association was found with positive expiratory pressure training (P < .01) and a trend towards an association for airway manipulation, including bronchoscopies and in- and extubations. CONCLUSIONS Our results show that major risk factors for airborne SARS-CoV-2 include short physical distance, high patient viral load, and poor room ventilation. AGPs, as traditionally defined, seem to be of secondary importance.
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Affiliation(s)
- Sara Thuresson
- Division of Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University, Lund, Sweden
| | - Carl Johan Fraenkel
- Department of Infection Control, Region Skåne, Lund, Sweden
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Swedenand
| | | | - Jonathan Soldemyr
- Division of Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University, Lund, Sweden
| | - Anders Widell
- Department of Translational Medicine, Lund University, Lund, Sweden
| | - Patrik Medstrand
- Department of Translational Medicine, Lund University, Lund, Sweden
| | - Malin Alsved
- Division of Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University, Lund, Sweden
| | - Jakob Löndahl
- Division of Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University, Lund, Sweden
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Conway Morris A, Sharrocks K, Bousfield R, Kermack L, Maes M, Higginson E, Forrest S, Pereira-Dias J, Cormie C, Old T, Brooks S, Hamed I, Koenig A, Turner A, White P, Floto RA, Dougan G, Gkrania-Klotsas E, Gouliouris T, Baker S, Navapurkar V. The Removal of Airborne Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and Other Microbial Bioaerosols by Air Filtration on Coronavirus Disease 2019 (COVID-19) Surge Units. Clin Infect Dis 2022; 75:e97-e101. [PMID: 34718446 PMCID: PMC8689842 DOI: 10.1093/cid/ciab933] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Indexed: 11/29/2022] Open
Abstract
Airborne severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected in a coronavirus disease 19 (COVID-19) ward before activation of HEPA-air filtration but not during filter operation; SARS-CoV-2 was again detected following filter deactivation. Airborne SARS-CoV-2 was infrequently detected in a COVID-19 intensive care unit. Bioaerosol was also effectively filtered.
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Affiliation(s)
- Andrew Conway Morris
- The John Farman ICU, Cambridge University Hospitals, National Health Service (NHS) Foundation Trust, Cambridge, United Kingdom
- University Division of Anaesthesia, Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Katherine Sharrocks
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Rachel Bousfield
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Clinical Microbiology Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Leanne Kermack
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Ellen Higginson
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joana Pereira-Dias
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Claire Cormie
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Tim Old
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Sophie Brooks
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Islam Hamed
- The John Farman ICU, Cambridge University Hospitals, National Health Service (NHS) Foundation Trust, Cambridge, United Kingdom
| | - Alicia Koenig
- The John Farman ICU, Cambridge University Hospitals, National Health Service (NHS) Foundation Trust, Cambridge, United Kingdom
| | - Andrew Turner
- Department of Clinical Engineering, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul White
- Department of Clinical Engineering, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Medical Technology Research Centre and School of Medicine, Anglia Ruskin University, Chelmsford, United Kingdom
| | - R Andres Floto
- Molecular Immunity Unit, University of Cambridge Department of Medicine, MRC-Laboratory of Molecular Biology, Cambridge, United Kingdom
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Effrossyni Gkrania-Klotsas
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Theodore Gouliouris
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Clinical Microbiology Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Vilas Navapurkar
- The John Farman ICU, Cambridge University Hospitals, National Health Service (NHS) Foundation Trust, Cambridge, United Kingdom
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Affiliation(s)
- Jason Chui
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Canada
| | - David Sc Hui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Matthew Tv Chan
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
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Jimenez JL, Marr LC, Randall K, Ewing ET, Tufekci Z, Greenhalgh T, Tellier R, Tang JW, Li Y, Morawska L, Mesiano‐Crookston J, Fisman D, Hegarty O, Dancer SJ, Bluyssen PM, Buonanno G, Loomans MGLC, Bahnfleth WP, Yao M, Sekhar C, Wargocki P, Melikov AK, Prather KA. What were the historical reasons for the resistance to recognizing airborne transmission during the COVID-19 pandemic? INDOOR AIR 2022; 32:e13070. [PMID: 36040283 PMCID: PMC9538841 DOI: 10.1111/ina.13070] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 05/05/2023]
Abstract
The question of whether SARS-CoV-2 is mainly transmitted by droplets or aerosols has been highly controversial. We sought to explain this controversy through a historical analysis of transmission research in other diseases. For most of human history, the dominant paradigm was that many diseases were carried by the air, often over long distances and in a phantasmagorical way. This miasmatic paradigm was challenged in the mid to late 19th century with the rise of germ theory, and as diseases such as cholera, puerperal fever, and malaria were found to actually transmit in other ways. Motivated by his views on the importance of contact/droplet infection, and the resistance he encountered from the remaining influence of miasma theory, prominent public health official Charles Chapin in 1910 helped initiate a successful paradigm shift, deeming airborne transmission most unlikely. This new paradigm became dominant. However, the lack of understanding of aerosols led to systematic errors in the interpretation of research evidence on transmission pathways. For the next five decades, airborne transmission was considered of negligible or minor importance for all major respiratory diseases, until a demonstration of airborne transmission of tuberculosis (which had been mistakenly thought to be transmitted by droplets) in 1962. The contact/droplet paradigm remained dominant, and only a few diseases were widely accepted as airborne before COVID-19: those that were clearly transmitted to people not in the same room. The acceleration of interdisciplinary research inspired by the COVID-19 pandemic has shown that airborne transmission is a major mode of transmission for this disease, and is likely to be significant for many respiratory infectious diseases.
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Affiliation(s)
- Jose L. Jimenez
- Department of Chemistry and Cooperative Institute for Research in Environmental SciencesUniversity of ColoradoBoulderColoradoUSA
| | - Linsey C. Marr
- Department of Civil and Environmental EngineeringVirginia TechBlacksburgVirginiaUSA
| | | | | | - Zeynep Tufekci
- School of JournalismColumbia UniversityNew YorkNew YorkUSA
| | - Trish Greenhalgh
- Department of Primary Care Health SciencesMedical Sciences DivisionUniversity of OxfordOxfordUK
| | | | - Julian W. Tang
- Department of Respiratory SciencesUniversity of LeicesterLeicesterUK
| | - Yuguo Li
- Department of Mechanical EngineeringUniversity of Hong KongHong KongChina
| | - Lidia Morawska
- International Laboratory for Air Quality and HeathQueensland University of TechnologyBrisbaneQueenslandAustralia
| | | | - David Fisman
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | - Orla Hegarty
- School of Architecture, Planning & Environmental PolicyUniversity College DublinDublinIreland
| | - Stephanie J. Dancer
- Department of MicrobiologyHairmyres Hospital, Glasgow, and Edinburgh Napier UniversityGlasgowUK
| | - Philomena M. Bluyssen
- Faculty of Architecture and the Built EnvironmentDelft University of TechnologyDelftThe Netherlands
| | - Giorgio Buonanno
- Department of Civil and Mechanical EngineeringUniversity of Cassino and Southern LazioCassinoItaly
| | - Marcel G. L. C. Loomans
- Department of the Built EnvironmentEindhoven University of Technology (TU/e)EindhovenThe Netherlands
| | - William P. Bahnfleth
- Department of Architectural EngineeringThe Pennsylvania State UniversityUniversity ParkPennsylvaniaUSA
| | - Maosheng Yao
- College of Environmental Sciences and EngineeringPeking UniversityBeijingChina
| | - Chandra Sekhar
- Department of the Built EnvironmentNational University of SingaporeSingaporeSingapore
| | - Pawel Wargocki
- Department of Civil EngineeringTechnical University of DenmarkLyngbyDenmark
| | - Arsen K. Melikov
- Department of Civil EngineeringTechnical University of DenmarkLyngbyDenmark
| | - Kimberly A. Prather
- Scripps Institution of OceanographyUniversity of California San DiegoLa JollaCaliforniaUSA
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Abstract
During the early phase of the COVID-19 pandemic, many respiratory therapies were classified as aerosol-generating procedures. This categorization resulted in a broad range of clinical concerns and a shortage of essential medical resources for some patients. In the past 2 years, many studies have assessed the transmission risk posed by various respiratory care procedures. These studies are discussed in this narrative review, with recommendations for mitigating transmission risk based on the current evidence.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois
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Prevention of SARS-CoV-2 and respiratory viral infections in healthcare settings: current and emerging concepts. Curr Opin Infect Dis 2022; 35:353-362. [PMID: 35849526 DOI: 10.1097/qco.0000000000000839] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW COVID-19 has catalyzed a wealth of new data on the science of respiratory pathogen transmission and revealed opportunities to enhance infection prevention practices in healthcare settings. RECENT FINDINGS New data refute the traditional division between droplet vs airborne transmission and clarify the central role of aerosols in spreading all respiratory viruses, including Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), even in the absence of so-called 'aerosol-generating procedures' (AGPs). Indeed, most AGPs generate fewer aerosols than talking, labored breathing, or coughing. Risk factors for transmission include high viral loads, symptoms, proximity, prolonged exposure, lack of masking, and poor ventilation. Testing all patients on admission and thereafter can identify early occult infections and prevent hospital-based clusters. Additional prevention strategies include universal masking, encouraging universal vaccination, preferential use of N95 respirators when community rates are high, improving native ventilation, utilizing portable high-efficiency particulate air filters when ventilation is limited, and minimizing room sharing when possible. SUMMARY Multifaceted infection prevention programs that include universal testing, masking, vaccination, and enhanced ventilation can minimize nosocomial SARS-CoV-2 infections in patients and workplace infections in healthcare personnel. Extending these insights to other respiratory viruses may further increase the safety of healthcare and ready hospitals for novel respiratory viruses that may emerge in the future.
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Gedge DA, Chilcott RP, Williams J. Quantifying the Risk to Health Care Workers of Cough as an Aerosol Generating Event in an Ambulance Setting: A Research Report. Prehosp Disaster Med 2022; 37:515-519. [PMID: 35713106 PMCID: PMC9280060 DOI: 10.1017/s1049023x22000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/12/2022] [Accepted: 04/30/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION AND OBJECTIVE United Kingdom Health Security Agency (UKHSA) guidance related to mask use for health care workers in a non-aerosol generating procedure (AGP) setting has remained as Level 2 water repellent paper mask (surgical mask) only. Energetic respiratory events, such as coughing, can generate vast numbers of droplets and aerosols. Coughing, considered to be a non-AGP event, frequently occurs in the relatively small, confined space of an ambulance (∼25 m3). The report seeks to explore whether existing research can provide an indication of the risk to ambulance staff, via aerosol transmission, of an acute respiratory infection (ARI) during a coughing event within the clinical setting of an ambulance. METHODS International bibliographic databases were searched (CINAHL Plus, SCOPUS, PubMed, and CENTRAL) using appropriate search strings and a combination of relevant medical subject headings with appropriate truncation. Methodological filters were not applied. Papers without an English language abstract were excluded from the review. Grey literature was sought by searching specialist databases OpenGrey and GreyNet, as well as key organizations' websites. The initial search identified 2,405 articles. Following screening, along with forward and backward citation of key papers identified within the literature search, 36 papers were deemed eligible for the scoping review. DISCUSSION Attempts to replicate a clinical environment to investigate the risk of transmission of airborne viruses to health care workers during a coughing event provided evidence for the generation of respirable aerosol particles and thus potential transmission of pathogens. In cases of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), potential to infect versus true airborne transmission is a debate that continues, but there is general consensus that a large variation of cough characteristics and aerosol generation amongst individuals exists. Studies widely endorsed face masks as a source control device, but there were conflicting views about the impact of mask leakage. CONCLUSION Further research is required to provide clarity of the risk to health care workers when caring for a coughing patient in the confined clinical ambulance setting and to provide an evidence base to assist in the determination of appropriate respiratory protective equipment (RPE).
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Affiliation(s)
- Dale A. Gedge
- University of Hertfordshire, School of Health and Social Work, Hatfield, Hertfordshire, United Kingdom
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, United Kingdom
| | - Robert P. Chilcott
- University of Hertfordshire, Toxicology Research Group, Hatfield, Hertfordshire, United Kingdom
| | - Julia Williams
- University of Hertfordshire, School of Health and Social Work, Hatfield, Hertfordshire, United Kingdom
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38
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Messer B, Armstrong AD, Lane ND, Robb A, Bullock RE. Exhaled gases and the potential for cross-infection via noninvasive ventilation machines. ERJ Open Res 2022; 8:00109-2022. [PMID: 35795308 PMCID: PMC9251366 DOI: 10.1183/23120541.00109-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/06/2022] [Indexed: 11/05/2022] Open
Abstract
Use of long-term ventilation (LTV) benefits patients with a diverse range of conditions, including Duchenne muscular dystrophy, motor neurone disease and scoliosis [1]. Patients with pulmonary disease as well as neuromuscular disease can benefit from LTV. COPD patients treated with LTV experience a reduction in hospital admissions and the use of LTV in cystic fibrosis (CF) patients is increasing [2, 3]. Guidelines suggest that exhaled gases do not reach the outlet of noninvasive ventilators in clinical use. In this study, when tidal volumes exceeded 800 mL, exhaled gases did reach the ventilator, leading to a risk of cross-infection between users.https://bit.ly/3EdvtY6
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Survey of coronavirus disease 2019 (COVID-19) infection control policies at leading US academic hospitals in the context of the initial pandemic surge of the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) omicron variant. Infect Control Hosp Epidemiol 2022; 44:597-603. [PMID: 35705223 PMCID: PMC9253430 DOI: 10.1017/ice.2022.155] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess coronavirus disease 2019 (COVID-19) infection policies at leading US medical centers in the context of the initial wave of the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) omicron variant. DESIGN Electronic survey study eliciting hospital policies on masking, personal protective equipment, cohorting, airborne-infection isolation rooms (AIIRs), portable HEPA filters, and patient and employee testing. SETTING AND PARTICIPANTS "Hospital epidemiologists from U.S. News top 20 hospitals and 10 hospitals in the CDC Prevention Epicenters program." As it is currently written, it implies all 30 hospitals are from the CDC Prevention Epicenters program, but that only applies to 10 hospitals. Alternatively, we could just say "Hospital epidemiologists from 30 leading US hospitals." METHODS Survey results were reported using descriptive statistics. RESULTS Of 30 hospital epidemiologists surveyed, 23 (77%) completed the survey between February 15 and March 3, 2022. Among the responding hospitals, 18 (78%) used medical masks for universal masking and 5 (22%) used N95 respirators. 16 hospitals (70%) required universal eye protection. 22 hospitals (96%) used N95s for routine COVID-19 care and 1 (4%) reserved N95s for aerosol-generating procedures. 2 responding hospitals (9%) utilized dedicated COVID-19 wards; 8 (35%) used mixed COVID-19 and non-COVID-19 units; and 13 (57%) used both dedicated and mixed units. 4 hospitals (17%) used AIIRs for all COVID-19 patients, 10 (43%) prioritized AIIRs for aerosol-generating procedures, 3 (13%) used alternate risk-stratification criteria (not based on aerosol-generating procedures), and 6 (26%) did not routinely use AIIRs. 9 hospitals (39%) did not use portable HEPA filters, but 14 (61%) used them for various indications, most commonly as substitutes for AIIRs when unavailable or for specific high-risk areas or situations. 21 hospitals (91%) tested asymptomatic patients on admission, but postadmission testing strategies and preferred specimen sites varied substantially. 5 hospitals (22%) required regular testing of unvaccinated employees and 1 hospital (4%) reported mandatory weekly testing even for vaccinated employees during the SARS-CoV-2 omicron surge. CONCLUSIONS COVID-19 infection control practices in leading hospitals vary substantially. Clearer public health guidance and transparency around hospital policies may facilitate more consistent national standards.
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Lands LC. Re-opening the pediatric pulmonary function laboratory during the ongoing COVID-19 pandemic. Paediatr Respir Rev 2022; 42:49-52. [PMID: 35428587 PMCID: PMC8756810 DOI: 10.1016/j.prrv.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 10/27/2022]
Abstract
The COVID-19 pandemic continues with new waves of intensification. This review provides an update based on international recommendations concerning the conduct of pulmonary function testing in a manner to limit risk to both patient and tester.
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41
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Shrimpton AJ, Brown JM, Cook TM, Penfold CM, Reid JP, Pickering AE. Quantitative evaluation of aerosol generation from upper airway suctioning assessed during tracheal intubation and extubation sequences in anaesthetized patients. J Hosp Infect 2022; 124:13-21. [PMID: 35276282 PMCID: PMC9172909 DOI: 10.1016/j.jhin.2022.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/17/2022] [Accepted: 02/28/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Open respiratory suctioning is defined as an aerosol generating procedure (AGP). Laryngopharyngeal suctioning, used to clear secretions during anaesthesia, is widely managed as an AGP. However, it is uncertain whether upper airway suctioning should be designated as an AGP due to the lack of both aerosol and epidemiological evidence. AIM To assess the relative risk of aerosol generation by upper airway suctioning during tracheal intubation and extubation in anaesthetized patients. METHODS This prospective environmental monitoring study was undertaken in an ultraclean operating theatre setting to assay aerosol concentrations during intubation and extubation sequences, including upper airway suctioning, for patients undergoing surgery (N=19). An optical particle sizer (particle size 0.3-10 μm) sampled aerosol 20 cm above the patient's mouth. Baseline recordings (background, tidal breathing and volitional coughs) were followed by intravenous induction of anaesthesia with neuromuscular blockade. Four periods of laryngopharyngeal suctioning were performed with a Yankauer sucker: pre-laryngoscopy, post-intubation, pre-extubation and post-extubation. FINDINGS Aerosol was reliably detected {median 65 [interquartile range (IQR) 39-259] particles/L} above background [median 4.8 (IQR 1-7) particles/L, P<0.0001] when sampling in close proximity to the patient's mouth during tidal breathing. Upper airway suctioning was associated with a much lower average aerosol concentration than breathing [median 6.0 (IQR 0-12) particles/L, P=0.0007], and was indistinguishable from background (P>0.99). Peak aerosol concentrations recorded during suctioning [median 45 (IQR 30-75) particles/L] were much lower than during volitional coughs [median 1520 (IQR 600-4363) particles/L, P<0.0001] and tidal breathing [median 540 (IQR 300-1826) particles/L, P<0.0001]. CONCLUSION Upper airway suctioning during airway management was not associated with a higher aerosol concentration compared with background, and was associated with a much lower aerosol concentration compared with breathing and coughing. Upper airway suctioning should not be designated as a high-risk AGP.
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Affiliation(s)
- A J Shrimpton
- Anaesthesia, Pain and Critical Care, School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK.
| | - J M Brown
- Department of Anaesthesia and Intensive Care Medicine, North Bristol NHS Trust, Bristol, UK
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital NHS Trust, Bath, UK
| | - C M Penfold
- Bristol Biomedical Research Centre, University of Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - J P Reid
- School of Chemistry, University of Bristol, Bristol, UK
| | - A E Pickering
- Anaesthesia, Pain and Critical Care, School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
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Mksoud M, Ittermann T, Holtfreter B, Söhnel A, Söhnel C, Welk A, Ulm L, Becker K, Hübner NO, Rau A, Kindler S, Kocher T. Prevalence of SARS-CoV-2 IgG antibodies among dental teams in Germany. Clin Oral Investig 2022; 26:3965-3974. [PMID: 35015149 PMCID: PMC8751466 DOI: 10.1007/s00784-021-04363-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/29/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES During the corona pandemic, dental practices temporarily closed their doors to patients except for emergency treatments. Due to the daily occupational exposure, the risk of SARS-CoV-2 transmission among dentists and their team is presumed to be higher than that in the general population. This study examined this issue among dental teams across Germany. MATERIALS AND METHODS In total, 2784 participants provided usable questionnaires and dry blood samples. Dry blood samples were used to detect IgG antibodies against SARS-CoV-2. The questionnaires were analyzed to investigate demographic data and working conditions during the pandemic. Multivariable logistic mixed-effects models were applied. RESULTS We observed 146 participants with positive SARS-CoV-2 IgG antibodies (5.2%) and 30 subjects with a borderline finding (1.1%). Seventy-four out of the 146 participants with SARS-CoV-2 IgG antibodies did not report a positive SARS-CoV-2 PCR test (50.7%), while 27 participants without SARS-CoV-2 IgG antibodies reported a positive SARS-CoV-2 PCR test (1.1%). Combining the laboratory and self-reported information, the number of participants with a SARS-CoV-2 infection was 179 (6.5%). Though after adjustment for region, mixed-effects models indicated associations of use of rubber dams (OR 1.65; 95% CI: 1.01-2.72) and the number of protective measures (OR 1.16; 95% CI: 1.01-1.34) with increased risk for positive SARS-CoV-2 status, none of those variables was significantly associated with a SARS-CoV-2 status in fully adjusted models. CONCLUSIONS The risk of SARS-CoV-2 transmission was not higher among the dental team compared to the general population. CLINICAL RELEVANCE Following hygienic regulations and infection control measures ensures the safety of the dental team and their patients.
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Affiliation(s)
- Maria Mksoud
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, University Medicine Greifswald, Walther-Rathenau-Str. 42a, 17475 Greifswald, Germany
| | - Till Ittermann
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Birte Holtfreter
- Department of Restorative Dentistry, Periodontology Endodontology and Preventive and Pediatric Dentistry, University Medicine Greifswald, Greifswald, Germany
| | - Andreas Söhnel
- Department of Prosthodontics, Gerodontology and Biomaterials, University Medicine Greifswald, Greifswald, Germany
| | - Carmen Söhnel
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, University Medicine Greifswald, Walther-Rathenau-Str. 42a, 17475 Greifswald, Germany
| | - Alexander Welk
- Department of Restorative Dentistry, Periodontology Endodontology and Preventive and Pediatric Dentistry, University Medicine Greifswald, Greifswald, Germany
| | - Lena Ulm
- Friedrich Loeffler-Institute of Medical Microbiology, University Medicine Greifswald, Greifswald, Germany
| | - Karsten Becker
- Friedrich Loeffler-Institute of Medical Microbiology, University Medicine Greifswald, Greifswald, Germany
| | - Nils-Olaf Hübner
- Central Unit for Infection Prevention and Control, University Medicine Greifswald, Greifswald, Germany
| | - Andrea Rau
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, University Medicine Greifswald, Walther-Rathenau-Str. 42a, 17475 Greifswald, Germany
| | - Stefan Kindler
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, University Medicine Greifswald, Walther-Rathenau-Str. 42a, 17475 Greifswald, Germany
| | - Thomas Kocher
- Department of Restorative Dentistry, Periodontology Endodontology and Preventive and Pediatric Dentistry, University Medicine Greifswald, Greifswald, Germany
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A comparison of respiratory particle emission rates at rest and while speaking or exercising. COMMUNICATIONS MEDICINE 2022; 2:44. [PMID: 35603287 PMCID: PMC9053213 DOI: 10.1038/s43856-022-00103-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 03/14/2022] [Indexed: 12/19/2022] Open
Abstract
Background The coronavirus disease-19 (COVID-19) pandemic led to the prohibition of group-based exercise and the cancellation of sporting events. Evaluation of respiratory aerosol emissions is necessary to quantify exercise-related transmission risk and inform mitigation strategies. Methods Aerosol mass emission rates are calculated from concurrent aerosol and ventilation data, enabling absolute comparison. An aerodynamic particle sizer (0.54–20 μm diameter) samples exhalate from within a cardiopulmonary exercise testing mask, at rest, while speaking and during cycle ergometer-based exercise. Exercise challenge testing is performed to replicate typical gym-based exercise and very vigorous exercise, as determined by a preceding maximally exhaustive exercise test. Results We present data from 25 healthy participants (13 males, 12 females; 36.4 years). The size of aerosol particles generated at rest and during exercise is similar (unimodal ~0.57–0.71 µm), whereas vocalization also generated aerosol particles of larger size (i.e. was bimodal ~0.69 and ~1.74 µm). The aerosol mass emission rate during speaking (0.092 ng s−1; minute ventilation (VE) 15.1 L min−1) and vigorous exercise (0.207 ng s−1, p = 0.726; VE 62.6 L min−1) is similar, but lower than during very vigorous exercise (0.682 ng s−1, p < 0.001; VE 113.6 L min−1). Conclusions Vocalisation drives greater aerosol mass emission rates, compared to breathing at rest. Aerosol mass emission rates in exercise rise with intensity. Aerosol mass emission rates during vigorous exercise are no different from speaking at a conversational level. Mitigation strategies for airborne pathogens for non-exercise-based social interactions incorporating vocalisation, may be suitable for the majority of exercise settings. However, the use of facemasks when exercising may be less effective, given the smaller size of particles produced. SARS-CoV-2, the virus that causes COVID-19, and other respiratory viruses are transmitted via respiratory particles emitted while breathing or speaking. Transmission of these viruses will depend in part on the rate at which these particles are emitted. Here, we studied respiratory particle sizes and emission rates in healthy people while breathing at rest, while speaking and during exercise on a static bicycle. We find that speaking generates larger particles and exercise generates smaller particles. The particle emission rate during speaking and typical gym-based exercise was similar but lower than values measured during very vigorous exercise. These findings help us to understand the emission of respiratory particles during different activities, and suggest that preventative measures for COVID-19 such as social distancing, used for non-exercise-based social interactions involving speaking, may be suitable for the majority of exercise settings. Orton and Symons et al. compare respiratory particle sizes and emission rates by sampling exhalates from participants at rest, and while speaking or exercising. They find that vocalisation produces larger particles and that while emission rates are similar between speaking and vigorous exercise, very vigorous exercise leads to higher rates.
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Sampol J, Sáez M, Martí S, Pallero M, Barrecheguren M, Ferrer J, Sampol G. Impact of home CPAP treated obstructive sleep apnea on COVID-19 outcomes in hospitalized patients. J Clin Sleep Med 2022; 18:1857-1864. [PMID: 35404224 PMCID: PMC9243267 DOI: 10.5664/jcsm.10016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To investigate the association between moderate or severe obstructive sleep apnea (OSA) treated with home continuous positive airway pressure (CPAP) and severe coronavirus disease 2019 (COVID-19). METHODS Retrospective study of patients admitted for COVID-19. Patients with OSA treated with home CPAP were identified and for each of them we selected 5 patients admitted consecutively in the following hours. The main outcome of the study was the development of severe COVID-19, defined as: a) death, or b) a composite outcome of death or the presence of severe hypoxemic respiratory failure at or during admission. The association between CPAP-treated OSA and these outcomes was estimated by logistic regression analysis after applying inverse probability of treatment weighting using a propensity score-weighting approach. RESULTS Of the 2059 patients admitted, 81 (3.9%) were receiving treatment with home CPAP. Among the 486 patients included in the study, 19% died and 39% presented the composite outcome. The logistic regression analysis did not show an association of CPAP treatment either with death (OR [95% CI]: 0.684 [0.332-1.409], p:0.303) or with the composite outcome (OR [95% CI]: 0.779 [0.418-1.452], p:0.432). Death was associated with age (OR [95% CI]: 1.116 [1.08-1.152], p<0.001) and number of comorbidities (OR [95% CI]: 1.318 [1.065-1.631], p:0.012), and the composite outcome was associated with male sex (OR [95% CI]: 2.067[1.19-3.589], p:0.01) and number of comorbidities (OR [95% CI]:1.241 [1.039-1.484], p:0.018). CONCLUSIONS In hospitalized COVID-19 patients, prior OSA treated with home CPAP is not independently associated with worse outcomes.
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Affiliation(s)
- Júlia Sampol
- Respiratory Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Multidisciplinary Sleep Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - María Sáez
- Respiratory Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Sergi Martí
- Respiratory Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Mercedes Pallero
- Respiratory Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Miriam Barrecheguren
- Respiratory Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Jaume Ferrer
- Respiratory Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Multidisciplinary Sleep Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Gabriel Sampol
- Respiratory Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Multidisciplinary Sleep Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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Oksanen L, Sanmark E, Sofieva S, Rantanen N, Lahelma M, Anttila V, Lehtonen L, Atanasova N, Pesonen E, Geneid A, Hyvärinen A. Aerosol generation during general anesthesia is comparable to coughing: An observational clinical study. Acta Anaesthesiol Scand 2022; 66:463-472. [PMID: 34951703 PMCID: PMC9303240 DOI: 10.1111/aas.14022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intubation, laryngoscopy, and extubation are considered highly aerosol-generating procedures, and additional safety protocols are used during COVID-19 pandemic in these procedures. However, previous studies are mainly experimental and have neither analyzed staff exposure to aerosol generation in the real-life operating room environment nor compared the exposure to aerosol concentrations generated during normal patient care. To assess operational staff exposure to potentially infectious particle generation during general anesthesia, we measured particle concentration and size distribution with patients undergoing surgery with Optical Particle Sizer. METHODS A single-center observative multidisciplinary clinical study in Helsinki University Hospital with 39 adult patients who underwent general anesthesia with tracheal intubation. Mean particle concentrations during different anesthesia procedures were statistically compared with cough control data collected from 37 volunteers to assess the differences in particle generation. RESULTS This study measured 25 preoxygenations, 30 mask ventilations, 28 intubations, and 24 extubations. The highest total aerosol concentration of 1153 particles (p)/cm³ was observed during mask ventilation. Preoxygenations, mask ventilations, and extubations as well as uncomplicated intubations generated mean aerosol concentrations statistically comparable to coughing. It is noteworthy that difficult intubation generated significantly fewer aerosols than either uncomplicated intubation (p = .007) or coughing (p = 0.006). CONCLUSIONS Anesthesia induction generates mainly small (<1 µm) aerosol particles. Based on our results, general anesthesia procedures are not highly aerosol-generating compared with coughing. Thus, their definition as high-risk aerosol-generating procedures should be re-evaluated due to comparable exposures during normal patient care. IMPLICATION STATEMENT The list of aerosol-generating procedures guides the use of protective equipments in hospitals. Intubation is listed as a high-risk aerosol-generating procedure, however, aerosol generation has not been measured thoroughly. We measured aerosol generation during general anesthesia. None of the general anesthesia procedures generated statistically more aerosols than coughing and thus should not be considered as higher risk compared to normal respiratory activities.
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Affiliation(s)
- Lotta‐Maria Oksanen
- Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
- Department of Otorhinolaryngology and Phoniatrics—Head and Neck SurgeryHelsinki University HospitalHelsinkiFinland
| | - Enni Sanmark
- Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
- Department of Otorhinolaryngology and Phoniatrics—Head and Neck SurgeryHelsinki University HospitalHelsinkiFinland
| | - Svetlana Sofieva
- Faculty of Biological and Environmental SciencesMolecular and Integrative Biosciences Research ProgrammeUniversity of HelsinkiHelsinkiFinland
| | - Noora Rantanen
- Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
- Department of Otorhinolaryngology and Phoniatrics—Head and Neck SurgeryHelsinki University HospitalHelsinkiFinland
| | - Mari Lahelma
- Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
- Department of Otorhinolaryngology and Phoniatrics—Head and Neck SurgeryHelsinki University HospitalHelsinkiFinland
- Faculty of Science, Mathematics and StatisticsUniversity of HelsinkiHelsinkiFinland
| | - Veli‐Jukka Anttila
- Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
- HUS Inflammation CentreHelsinki University HospitalHelsinkiFinland
| | - Lasse Lehtonen
- Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
- HUS Diagnostic CentreHUSLABHelsinki University HospitalHelsinkiFinland
| | - Nina Atanasova
- Faculty of Biological and Environmental SciencesMolecular and Integrative Biosciences Research ProgrammeUniversity of HelsinkiHelsinkiFinland
- Finnish Meteorological InstituteHelsinkiFinland
| | - Eero Pesonen
- Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
- Department of Anesthesiology, Intensive Care and Pain MedicineHelsinki University HospitalHelsinkiFinland
| | - Ahmed Geneid
- Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
- Department of Otorhinolaryngology and Phoniatrics—Head and Neck SurgeryHelsinki University HospitalHelsinkiFinland
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Barnett A, Beasley R, Buchan C, Chien J, Farah CS, King G, McDonald CF, Miller B, Munsif M, Psirides A, Reid L, Roberts M, Smallwood N, Smith S. Thoracic Society of Australia and New Zealand Position Statement on Acute Oxygen Use in Adults: 'Swimming between the flags'. Respirology 2022; 27:262-276. [PMID: 35178831 PMCID: PMC9303673 DOI: 10.1111/resp.14218] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/28/2021] [Accepted: 01/03/2022] [Indexed: 12/14/2022]
Abstract
Oxygen is a life-saving therapy but, when given inappropriately, may also be hazardous. Therefore, in the acute medical setting, oxygen should only be given as treatment for hypoxaemia and requires appropriate prescription, monitoring and review. This update to the Thoracic Society of Australia and New Zealand (TSANZ) guidance on acute oxygen therapy is a brief and practical resource for all healthcare workers involved with administering oxygen therapy to adults in the acute medical setting. It does not apply to intubated or paediatric patients. Recommendations are made in the following six clinical areas: assessment of hypoxaemia (including use of arterial blood gases); prescription of oxygen; peripheral oxygen saturation targets; delivery, including non-invasive ventilation and humidified high-flow nasal cannulae; the significance of high oxygen requirements; and acute hypercapnic respiratory failure. There are three sections which provide (1) a brief summary, (2) recommendations in detail with practice points and (3) a detailed explanation of the reasoning and evidence behind the recommendations. It is anticipated that these recommendations will be disseminated widely in structured programmes across Australia and New Zealand.
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Affiliation(s)
- Adrian Barnett
- Department of Respiratory and Sleep MedicineMater Public HospitalSouth BrisbaneQueenslandAustralia
| | - Richard Beasley
- Medical Research Institute of New Zealand & Capital Coast District Health BoardWellingtonNew Zealand
| | - Catherine Buchan
- Department of Respiratory and Sleep MedicineThe Alfred HospitalMelbourneVictoriaAustralia
- Department of Immunology and Respiratory MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Jimmy Chien
- Department of Respiratory and Sleep MedicineWestmead Hospital, Ludwig Engel Centre for Respiratory Research and University of SydneySydneyNew South WalesAustralia
| | - Claude S. Farah
- Department of Respiratory Medicine, Concord HospitalMacquarie University and University of SydneySydneyNew South WalesAustralia
| | - Gregory King
- Department of Respiratory and Sleep Medicine, Royal North Shore HospitalWoolcock Institute of Medical Research and University of SydneySydneyNew South WalesAustralia
| | - Christine F. McDonald
- Department of Respiratory and Sleep MedicineAustin Health and University of MelbourneMelbourneVictoriaAustralia
| | - Belinda Miller
- Department of Respiratory MedicineThe Alfred Hospital and Monash UniversityMelbourneVictoriaAustralia
| | - Maitri Munsif
- Department of Respiratory and Sleep MedicineAustin Health and University of MelbourneMelbourneVictoriaAustralia
| | - Alex Psirides
- Intensive Care UnitWellington Regional Hospital, Capital and Coast District Health BoardWellingtonNew Zealand
| | - Lynette Reid
- Respiratory MedicineRoyal Hobart HospitalHobartTasmaniaAustralia
| | - Mary Roberts
- Department of Respiratory and Sleep MedicineWestmead Hospital, Ludwig Engel Centre for Respiratory Research and University of SydneySydneyNew South WalesAustralia
| | - Natasha Smallwood
- Department of Respiratory and Sleep MedicineThe Alfred HospitalMelbourneVictoriaAustralia
- Department of Immunology and Respiratory MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Sheree Smith
- School of Nursing and MidwiferyWestern Sydney UniversitySydneyNew South WalesAustralia
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Li J, A Alolaiwat A, J Harnois L, Fink JB, Dhand R. Mitigating Fugitive Aerosols During Aerosol Delivery via High-Flow Nasal Cannula Devices. Respir Care 2022; 67:404-414. [PMID: 34789564 PMCID: PMC9994017 DOI: 10.4187/respcare.09589] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Aerosol delivery via high-flow nasal cannula (HFNC) has attracted clinical interest in recent years. However, both HFNC and nebulization are categorized as aerosol-generating procedures (AGPs). In vitro studies raised concerns that AGPs had high transmission risk. Very few in vivo studies examined fugitive aerosols with nebulization via HFNC, and effective methods to mitigate aerosol dispersion are unknown. METHODS Two HFNC devices (Airvo 2 and Vapotherm) with or without a vibrating mesh nebulizer were compared; HFNC alone, surgical mask over HFNC interface, and HFNC with face tent scavenger were used in a random order for 9 healthy volunteers. Fugitive aerosol concentrations at sizes of 0.3-10.0 μm were continuously measured by particle sizers placed at 1 and 3 ft from participants. On a different day, 6 of the 9 participants received 6 additional nebulizer treatments via vibrating mesh nebulizer or small-volume nebulizer (SVN) with a face mask or a mouthpiece with/without an expiratory filter. In vitro simulation was employed to quantify inhaled dose of albuterol with vibrating mesh nebulizer via Airvo 2 and Vapotherm. RESULTS Compared to baseline, neither HFNC device generated higher aerosol concentrations. Compared to HFNC alone, vibrating mesh nebulizer via Airvo 2 generated higher 0.3-1.0 μm particles (all P < .05), but vibrating mesh nebulizer via Vapotherm did not. Concentrations of 1.0-3.0 μm particles with vibrating mesh nebulizer via Airvo 2 were similar with vibrating mesh nebulizer and a mouthpiece/face mask but less than SVN with a mouthpiece/face mask (all P < .05). Placing a surgical mask over HFNC during nebulization reduced 0.5-1.0 μm particles (all P < .05) to levels similar to the use of a nebulizer with mouthpiece and expiratory filter. In vitro the inhaled dose of albuterol with vibrating mesh nebulizer via Airvo 2 was ≥ 6 times higher than vibrating mesh nebulizer via Vapotherm. CONCLUSIONS During aerosol delivery via HFNC, Airvo 2 generated higher inhaled dose and consequently higher fugitive aerosols than Vapotherm. Simple measures, such as placing a surgical mask over nasal cannula during nebulization via HFNC, could effectively reduce fugitive aerosol concentrations.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois.
| | - Amnah A Alolaiwat
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois
| | - Lauren J Harnois
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois; and Aerogen Pharma Corp, San Mateo, California
| | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee
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Allison J, Dowson C, Pickering K, Červinskytė G, Durham J, Jakubovics N, Holliday R. Local Exhaust Ventilation to Control Dental Aerosols and Droplets. J Dent Res 2022; 101:384-391. [PMID: 34757884 PMCID: PMC8935467 DOI: 10.1177/00220345211056287] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Dental procedures produce aerosols that may remain suspended and travel significant distances from the source. Dental aerosols and droplets contain oral microbes, and there is potential for infectious disease transmission and major disruption to dental services during infectious disease outbreaks. One method to control hazardous aerosols often used in industry is local exhaust ventilation (LEV). The aim of this study was to investigate the effect of LEV on aerosols and droplets produced during dental procedures. Experiments were conducted on dental mannequins in an 825.4-m3 open-plan clinic and a 49.3-m3 single surgery. Ten-minute crown preparations were performed with an air-turbine handpiece in the open-plan clinic and 10-min full-mouth ultrasonic scaling in the single surgery. Fluorescein was added to instrument irrigation reservoirs as a tracer. In both settings, optical particle counters (OPCs) were used to measure aerosol particles between 0.3 and 10.0 µm, and liquid cyclone air samplers were used to capture aerosolized fluorescein tracer. In addition, in the open-plan setting, fluorescein tracer was captured by passive settling onto filter papers in the environment. Tracer was quantified fluorometrically. An LEV device with high-efficiency particulate air filtration and a flow rate of 5,000 L/min was used. LEV reduced aerosol production from the air-turbine handpiece by 90% within 0.5 m, and this was 99% for the ultrasonic scaler. OPC particle counts were substantially reduced for both procedures and air-turbine settled droplet detection reduced by 95% within 0.5 m. The effect of LEV was substantially greater than suction alone for the air-turbine and was similar to the effect of suction for the ultrasonic scaler. LEV reduces aerosol and droplet contamination from dental procedures by at least 90% in the breathing zone of the operator, and it is therefore a valuable tool to reduce the dispersion of dental aerosols.
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Affiliation(s)
- J.R. Allison
- School of Dental Sciences, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - C. Dowson
- School of Dental Sciences, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - K. Pickering
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - G. Červinskytė
- School of Dental Sciences, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - J. Durham
- School of Dental Sciences, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - N.S. Jakubovics
- School of Dental Sciences, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - R. Holliday
- School of Dental Sciences, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Schimmel M, Berkowitz DM. Pulmonary Procedures in the COVID-19 Era. CURRENT PULMONOLOGY REPORTS 2022; 11:39-47. [PMID: 35371910 PMCID: PMC8960220 DOI: 10.1007/s13665-022-00285-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review The purpose of this review is to discuss the impact of the COVID-19 pandemic on pulmonary procedures, including new guidelines, restrictions, techniques, and overall effect on patient care. Recent Findings SARS-CoV-2 predominately impacts the pulmonary system and can result in a severe lower respiratory tract infection. Early guidelines based largely on data from the SARS epidemic recommended significant restrictions on procedure volume out of concern for healthcare worker safety. Newer data suggests relative safety in performing airway and pleural procedures as long as appropriate precautions are followed and new techniques are utilized. The introduction of effective vaccines and more reliable testing has led to a re-expansion of elective procedures. Summary Many guidelines and expert statements exist for the management and practice of pulmonary procedures during the COVID-19 pandemic. A flexible and individualized approach may be necessary as our understanding of COVID-19 continues to evolve.
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Affiliation(s)
- Matt Schimmel
- Division of Interventional Pulmonology, Emory University, Atlanta, GA USA
| | - David M. Berkowitz
- Division of Interventional Pulmonology, Emory University, Atlanta, GA USA
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Klompas M, Baker M, Rhee C. COVID-19's Challenges to Infection Control Dogma Regarding Respiratory Virus Transmission. Clin Infect Dis 2022; 75:e102-e104. [PMID: 35271714 DOI: 10.1093/cid/ciac204] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Indexed: 12/29/2022] Open
Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Meghan Baker
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA
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