Quantitative evaluation of aerosol generation from upper airway suctioning assessed during tracheal intubation and extubation sequences in anaesthetized patients

A.J Shrimpton,J.M Brown,T.M Cook,C.M Penfold,J.P Reid,A.E Pickering

doi:10.1016/j.jhin.2022.02.021

A.J Shrimpton, J.M Brown + Show 4 more

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https://doi.org/10.1016/j.jhin.2022.02.021

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Abstract

SummaryBackgroundOpen 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.AimTo assess the relative risk of aerosol generation by upper airway suctioning during tracheal intubation and extubation in anaesthetized patients.MethodsThis 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.FindingsAerosol 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].ConclusionUpper 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.

Highlights

Airway suctioning is a potentially life-saving medical intervention performed in a wide range of settings both within hospitals and in the community
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 aerosol generating procedure (AGP)

Summary

Introduction

Airway suctioning is a potentially life-saving medical intervention performed in a wide range of settings both within hospitals and in the community. Placement of a Yankaeur-type sucker into the laryngopharynx to clear secretions around the glottic inlet prior to tracheal intubation and following extubation constitutes open suctioning beyond the oropharynx (Figure 1). As such, this intervention, which is commonly performed during tracheal intubation/extubation sequences, is managed as an AGP, which necessitates the use of airborne personal protective equipment (PPE) and fallow time after its performance. With over 1.2 million general anaesthetics performed using a tracheal tube per year in the UK alone, upper airway suctioning during general anaesthesia provides a useful model to determine the risk of aerosol generation associated with this medical procedure [5].

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