Aerosol-generating otolaryngology procedures and the need for enhanced PPE during the COVID-19 pandemic: a literature review

BACKGROUND

Adequate personal protective equipment is needed to reduce the rate of transmission of COVID-19 to health care workers. Otolaryngology groups are recommending a higher level of personal protective equipment for aerosol-generating procedures than public health agencies. The objective of the review was to provide evidence that a.) demonstrates which otolaryngology procedures are aerosol-generating, and that b.) clarifies whether the higher level of PPE advocated by otolaryngology groups is justified.

MAIN BODY

Health care workers in China who performed tracheotomy during the SARS-CoV-1 epidemic had 4.15 times greater odds of contracting the virus than controls who did not perform tracheotomy (95% CI 2.75-7.54). No other studies provide direct epidemiological evidence of increased aerosolized transmission of viruses during otolaryngology procedures. Experimental evidence has shown that electrocautery, advanced energy devices, open suctioning, and drilling can create aerosolized biological particles. The viral load of COVID-19 is highest in the upper aerodigestive tract, increasing the likelihood that aerosols generated during procedures of the upper aerodigestive tract of infected patients would carry viral material. Cough and normal breathing create aerosols which may increase the risk of transmission during outpatient procedures. A significant proportion of individuals infected with COVID-19 may not have symptoms, raising the likelihood of transmission of the disease to inadequately protected health care workers from patients who do not have probable or confirmed infection. Powered air purifying respirators, if used properly, provide a greater level of filtration than N95 masks and thus may reduce the risk of transmission.

CONCLUSION

Direct and indirect evidence suggests that a large number of otolaryngology-head and neck surgery procedures are aerosol generating. Otolaryngologists are likely at high risk of contracting COVID-19 during aerosol generating procedures because they are likely exposed to high viral loads in patients infected with the virus. Based on the precautionary principle, even though the evidence is not definitive, adopting enhanced personal protective equipment protocols is reasonable based on the evidence. Further research is needed to clarify the risk associated with performing various procedures during the COVID-19 pandemic, and the degree to which various personal protective equipment reduces the risk.

Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic

INTRODUCTION

The performance of tracheotomy is a common procedural request by critical care departments to the surgical services of general surgery, thoracic surgery and otolaryngology - head & neck surgery. A Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force was convened with multi-specialty involvement from otolaryngology-head & neck surgery, general surgery, critical care and anesthesiology to develop a set of recommendations for the performance of tracheotomies during the COVID-19 pandemic.

MAIN BODY

The tracheotomy procedure is highly aerosol generating and directly exposes the entire surgical team to the viral aerosol plume and secretions, thereby increasing the risk of transmission to healthcare providers. As such, we believe extended endotracheal intubation should be the standard of care for the entire duration of ventilation in the vast majority of patients. Pre-operative COVID-19 testing is highly recommended for any non-emergent procedure.

CONCLUSION

The set of recommendations in this document highlight the importance of avoiding tracheotomy procedures in patients who are COVID-19 positive if at all possible. Recommendations for appropriate PPE and environment are made for COVID-19 positive, negative and unknown patients requiring consideration of tracheotomy. The safety of healthcare professionals who care for ill patients and who keep critical infrastructure operating is paramount.