Abstract
SummaryThe potential aerosolised transmission of severe acute respiratory syndrome coronavirus‐2 is of global concern. Airborne precaution personal protective equipment and preventative measures are universally mandated for medical procedures deemed to be aerosol generating. The implementation of these measures is having a huge impact on healthcare provision. There is currently a lack of quantitative evidence on the number and size of airborne particles produced during aerosol‐generating procedures to inform risk assessments. To address this evidence gap, we conducted real‐time, high‐resolution environmental monitoring in ultraclean ventilation operating theatres during tracheal intubation and extubation sequences. Continuous sampling with an optical particle sizer allowed characterisation of aerosol generation within the zone between the patient and anaesthetist. Aerosol monitoring showed a very low background particle count (0.4 particles.l−1) allowing resolution of transient increases in airborne particles associated with airway management. As a positive reference control, we quantitated the aerosol produced in the same setting by a volitional cough (average concentration, 732 (418) particles.l−1, n = 38). Tracheal intubation including facemask ventilation produced very low quantities of aerosolised particles (average concentration, 1.4 (1.4) particles.l−1, n = 14, p < 0.0001 vs. cough). Tracheal extubation, particularly when the patient coughed, produced a detectable aerosol (21 (18) l−1, n = 10) which was 15‐fold greater than intubation (p = 0.0004) but 35‐fold less than a volitional cough (p < 0.0001). The study does not support the designation of elective tracheal intubation as an aerosol‐generating procedure. Extubation generates more detectable aerosol than intubation but falls below the current criterion for designation as a high‐risk aerosol‐generating procedure. These novel findings from real‐time aerosol detection in a routine healthcare setting provide a quantitative methodology for risk assessment that can be extended to other airway management techniques and clinical settings. They also indicate the need for reappraisal of what constitutes an aerosol‐generating procedure and the associated precautions for routine anaesthetic airway management.
Highlights
The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and associated coronavirus disease 2019 (COVID-19) pandemic have had an unprecedented impact on global health and the world economy
Recordings were made of 19 intubations and 14 extubations
The conduct of anaesthesia was left at the discretion of the anaesthetist, who ranged in experience from junior trainee to senior consultant
Summary
The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and associated coronavirus disease 2019 (COVID-19) pandemic have had an unprecedented impact on global health and the world economy. Coughing and sneezing atomise respiratory secretions into particles with different aerodynamic properties according to size; particles greater than 20 μm in diameter are conventionally defined as droplets and tend to follow a ballistic trajectory. These droplets can either directly contact and infect a susceptible individual within close proximity or may settle on nearby surfaces (fomites) where viable virus can exist for up to 72 h [2, 3]. This direct droplet and indirect contact transmission are considered the predominant modes of spread of SARSCoV-2, providing the rationale for physical distancing and hand hygiene as primary measures to reduce the incidence of COVID-19
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