High-risk Aerosol-generating Procedures Research Articles

Comparing the Ease of Endotracheal Intubation with and without an Intubation Box in COVID-19 Patients

Background: Endotracheal intubation is a potentially high-risk aerosol-generating procedure. So, an intubation box (I-Box) is designed for personal protection during intubation. This study aimed to compare the outcomes of endotracheal intubation with and without an I-box in COVID-19 patients. Methods: In this study, 60 COVID-19 patients (30 patients in each group) with and without I-box groups were included. outcomes of intubation including duration of intubation, first-pass success intubation, suitable visibility of airways, restriction of movement in the neck, the need to surface maneuvering of the airway, and the number of attempts for successful intubation were compared between the two groups. Results: The time of intubation was significantly longer in the I-box group (15.27±2.6 seconds) than without the I-box group (8.37±1.3 seconds) (p<0.001). All patients (100%) were intubated in the first attempt in the without I-box group while the rate of first-pass success intubation was 50% in the I-box group (p <0.001). The visibility of the airway was significantly better in the without I-box group than the I-box group (without I-box: 23 patients (76.7%), I-box: 15 patients (50%), p= 0.032). The frequency of need to optimizing maneuver of the airway was in without and with I-box was 23.3% and 50% respectively (p=0.032). Conclusion: However, the I-box as a physical barrier can protect healthcare workers but its use increased the time to intubation and the number of attempts for successful intubation and reduced the rate of first-pass success intubation and visibility.

Comparing the Ease of Endotracheal Intubation with and without an Intubation Box in COVID-19 Patients

Background: Endotracheal intubation is a potentially high-risk aerosol-generating procedure. So, an intubation box (I-Box) is designed for personal protection during intubation. This study aimed to compare the outcomes of endotracheal intubation with and without an I-box in COVID-19 patients. Methods: In this study, 60 COVID-19 patients (30 patients in each group) with and without I-box groups were included. outcomes of intubation including duration of intubation, first-pass success intubation, suitable visibility of airways, restriction of movement in the neck, the need to surface maneuvering of the airway, and the number of attempts for successful intubation were compared between the two groups. Results: The time of intubation was significantly longer in the I-box group (15.27±2.6 seconds) than without the I-box group (8.37±1.3 seconds) (p<0.001). All patients (100%) were intubated in the first attempt in the without I-box group while the rate of first-pass success intubation was 50% in the I-box group (p <0.001). The visibility of the airway was significantly better in the without I-box group than the I-box group (without I-box: 23 patients (76.7%), I-box: 15 patients (50%), p= 0.032). The frequency of need to optimizing maneuver of the airway was in without and with I-box was 23.3% and 50% respectively (p=0.032). Conclusion: However, the I-box as a physical barrier can protect healthcare workers but its use increased the time to intubation and the number of attempts for successful intubation and reduced the rate of first-pass success intubation and visibility.

Emerging Roles of Malaysian Pharmacists in Asthma Management Amidst the COVID-19 Pandemic: A Narrative Review.

The arrival of COVID-19 pandemic in March 2020 adversely affected every aspect of human life, including the management of asthma. The pandemic has forced clinicians to revisit the application of high-risk aerosol-generating procedures in asthma management, including spirometry and nebuliser therapy. The use of commercial spacers with pressurised metered-dose inhalers to replace nebulisation is limited by the high cost and pandemic-induced stock unavailability of these inhalers. The need for social distancing, healthcare reserves reallocation, and scarce personal protective equipment has promote increased telemedicine uptake for patients' asthma control and monitoring. Malaysian pharmacists have been providing long-term care of asthma through the introduction of the respiratory Medication Therapy Adherence Clinic (MTAC) to empower patients' general health literacy, train and regularly evaluate their inhalation technique, and reinforce the importance of medication compliance. To minimise the use of unplanned healthcare resources and avoidable COVID-19 infection exposure, Malaysian pharmacists need to better support asthma self-management via increased uptake of written Asthma Action Plans (AAPs). Pharmacist-led asthma treatment step-down to attain the lowest effective dose of inhaled corticosteroids (ICS) has become increasingly relevant during the pandemic, as its prolonged use carries risk of numerous side effects and possible hospitalisation. Telepharmacy offers a promising model for exploration and an alternative to the traditional service delivery of asthma education. Despite not being authorised as vaccinators, Malaysian pharmacists hold strong positions in COVID-19 immunisation programmes for pharmacovigilance and advocacy. The pandemic demands an increased role for pharmacists within medication management to prevent patients from the stockpiling that can cause adverse effects on pharmaceutical supply chain. This review intends to summarise the impact of COVID-19 on asthma management, with a focus on the transitional roles of Malaysian pharmacists before and after the pandemic era.

Impact of COVID-19 on endoscopic follow-up of gastroesophageal varices

BackgroundPortal hypertension is considered as a major complication of liver cirrhosis. Endoscopy plays a main role in managing of gastrointestinal complications of portal hypertension. Endoscopists are at increased risk for COVID-19 infection because upper gastrointestinal (GI) endoscopy is a high-risk aerosol-generating procedure and may be a potential route for COVID-19.ObjectivesTo compare the outcome between cirrhotic patients who underwent classic regular endoscopic variceal ligation after primary bleeding episode every 2–4 weeks, and those presented during the era of COVID-19 and their follow-up were postponed 2 months later.MethodsThis retrospective study included cross-matched 238 cirrhotic patients with portal hypertension presented with upper GI bleeding, 112 cirrhotic patients presented during the era of COVID19 (group A) underwent endoscopic variceal ligation, another session after 2 weeks and their subsequent follow-up was postponed 2 months later, and 126 cirrhotic patients as control (group B) underwent regular endoscopic variceal band ligation after primary bleeding episode every 2–4 weeks.ResultsEradication of varices was achieved in 32% of cases in group A, and 46% in group was not any statistically significant (p > 0.05); also, there was no any statistical significant difference between both groups regarding occurrence of rebleeding, post endoscopic symptoms, and mortality rate (p > 0.05).ConclusionBand ligation and injection of esophageal and gastric vary every 2 months were as effective and safe as doing it every 2 to 4 weeks after primary bleeding episode for further studies and validation.

Effect of FFP2/3 Masks on Voice Range Profile Measurement and Voice Acoustics in Routine Voice Diagnostics

Introduction: Voice diagnostics including voice range profile (VRP) measurement and acoustic voice analysis is essential in laryngology and phoniatrics. Due to COVID-19 pandemic, wearing of 2 or 3 filtering face piece (FFP2/3) masks is recommended when high-risk aerosol-generating procedures like singing and speaking are being performed. Goal of this study was to compare VRP parameters when performed without and with FFP2/3 masks. Further, formant analysis for sustained vowels, singer’s formant, and analysis of reading standard text samples were performed without/with FFP2/3 masks. Methods: Twenty subjects (6 males and 14 females) were enrolled in this study with an average age of 36 ± 16 years (mean ± SD). Fourteen patients were rated as euphonic/not hoarse and 6 patients as mildly hoarse. All subjects underwent the VRP measurements, vowel, and text recordings without/with FFP2/3 mask using the software DiVAS by XION medical (Berlin, Germany). Voice range of singing voice, equivalent of voice extension measure (eVEM), fundamental frequency (F0), sound pressure level (SPL) of soft speaking and shouting were calculated and analyzed. Maximum phonation time (MPT) and jitter-% were included for Dysphonia Severity Index (DSI) measurement. Analyses of singer’s formant were performed. Spectral analyses of sustained vowels /a:/, /i:/, and /u:/ (first = F1 and second = F2 formants), intensity of long-term average spectrum, and alpha-ratio were calculated using the freeware praat. Results: For all subjects, the mean values of routine voice parameters without/with mask were analyzed: no significant differences were found in results of singing voice range, eVEM, SPL, and frequency of soft speaking/shouting, except significantly lower mean SPL of shouting with FFP2/3 mask, in particular that of the female subjects (p = 0.002). Results of MPT, jitter, and DSI without/with FFP2/3 mask showed no significant differences. Further mean values analyzed without/with mask were ratio singer’s formant/loud singing, with lower ratio with FFP2/3 mask (p = 0.001), and F1 and F2 of /a:/, /i:/, /u:/, with no significant differences of the results, with the exception of F2 of /i:/ with lower value with FFP2/3 mask (p = 0.005). With the exceptions mentioned, the t test revealed no significant differences for each of the routine parameters tested in the recordings without and with wearing a FFP2/3 mask. Conclusion: It can be concluded that VRP measurements including DSI performed with FFP2/3 masks provide reliable data in clinical routine with respect to voice condition/constitution. Spectral analyses of sustained vowel, text, and singer’s formant will be affected by wearing FFP2/3 masks.

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

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.

Aerosol generation during general anesthesia is comparable to coughing: An observational clinical study.

ABSTRACTBackgroundIntubation, 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.MethodsA 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.ResultsThis 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).ConclusionsAnesthesia 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 StatementThe 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.

Microdebrider is less aerosol-generating than CO2 laser and cold instruments in microlaryngoscopy

ObjectiveCOVID-19 spreads through aerosols produced in coughing, talking, exhalation, and also in some surgical procedures. Use of CO2 laser in laryngeal surgery has been observed to generate aerosols, however, other techniques, such cold dissection and microdebrider, have not been sufficiently investigated. We aimed to assess whether aerosol generation occurs during laryngeal operations and the effect of different instruments on aerosol production.MethodsWe measured particle concentration generated during surgeries with an Optical Particle Sizer. Cough data collected from volunteers and aerosol concentration of an empty operating room served as references. Aerosol concentrations when using different techniques and equipment were compared with references as well as with each other.ResultsThirteen laryngological surgeries were evaluated. The highest total aerosol concentrations were observed when using CO2 laser and these were significantly higher than the concentrations when using microdebrider or cold dissection (p < 0.0001, p < 0.0001) or in the background or during coughing (p < 0.0001, p < 0.0001). In contrast, neither microdebrider nor cold dissection produced significant concentrations of aerosol compared with coughing (p = 0.146, p = 0.753). In comparing all three techniques, microdebrider produced the least aerosol particles.ConclusionsMicrodebrider and cold dissection can be regarded as aerosol-generating relative to background reference concentrations, but they should not be considered as high-risk aerosol-generating procedures, as the concentrations are low and do not exceed those of coughing. A step-down algorithm from CO2 laser to cold instruments and microdebrider is recommended to lower the risk of airborne infections among medical staff.

Bronchoscopy during COVID-19 pandemic, ventilatory strategies and procedure measures.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has changed bronchoscopy practices worldwide. Bronchoscopy is a high-risk aerosol-generating procedure with a potential for direct SARS-CoV-2 exposure and hospital-acquired infection. Current guidelines about personal protective equipment and environment considerations represent key competencies to minimize droplets dispersion and reduce the risk of transmission. Different measures should be put in field based on setting, patient's clinical characteristics, urgency and indications of bronchoscopy. The use of this technique in SARS-CoV-2 patients is reported primarily for removal of airway plugs and for obtaining microbiological culture samples. In mechanically ventilated patients with SARS-CoV-2, bronchoscopy is commonly used to manage complications such as hemoptysis, atelectasis or lung collapse when prone positioning, physiotherapy or recruitment maneuvers have failed. Further indications are represented by assistance during percutaneous tracheostomy. Continuous positive airway pressure, non-invasive ventilation support and high flow nasal cannula oxygen are frequently used in patient affected by Coronavirus disease 2019 (COVID-19): management of patients' airways and ventilation strategies differs from bronchoscopy indications, patient's clinical status and in course or required ventilatory support. Sedation is usually administered by the pulmonologist (performing the bronchoscopy) or by the anesthetist depending on the complexity of the procedure and the level of sedation required. Lastly, elective bronchoscopy for diagnostic indications during COVID-19 pandemic should be carried on respecting rigid standards which allow to minimize potential viral transmission, independently from patient's COVID-19 status. This narrative review aims to evaluate the indications, procedural measures and ventilatory strategies of bronchoscopy performed in different settings during COVID-19 pandemic.

Management of gastrointestinal bleeding during COVID-19: less is more!

Management of gastrointestinal bleeding during COVID-19: less is more!

The Use of Modified Snorkel Masks as Personal Protective Equipment During Aerosol-Generating Procedures: COVID-19 Necessity.

Background: The available personal protective equipment (PPE) is insufficient to provide adequate protection during high-risk aerosol-generating procedures, and their shortage was reported. The full-face snorkel masks were modified to be used as PPE. However, little is known about their use in medical practice. Methods: The available masks were assessed and compared in terms of safety, comfort, visual acuity, and communication with team members during the aerosol-generating surgical and endoscopic procedures. The masks were compared with a standard option (full-face shield and N95 mask). The score was assigned to each domain to compare the masks. The aim of the study was to assess the modified full-face snorkel masks as PPE during surgical and endoscopic aerosol-generating procedures. Results: Four modified snorkel masks were assessed and compared with the standard option. All masks provided a good seal, comfort, vision, and protection. Communication was the biggest problem and improved after modification. Suggestions for the mask's selection and on further improvements were made. Conclusion: The modified snorkel masks seem a good alternative to the standard PPE during aerosol-generating procedures. However, additional improvements are still needed. More studies are required to prove the benefits of the modified snorkel masks over the standard PPE.

Transnasal humidified rapid-insufflation ventilatory exchange ('THRIVE') in the coronavirus disease 2019 pandemic.

Since the start of the coronavirus disease 2019 pandemic, transnasal humidified rapid-insufflation ventilatory exchange ('THRIVE') has been classified as a high-risk aerosol-generating procedure and is strongly discouraged, despite a lack of conclusive evidence on its safety. This study aimed to investigate the safety of transnasal humidified rapid-insufflation ventilatory exchange usage and its impact on staff members. A prospective study was conducted on all transnasal humidified rapid-insufflation ventilatory exchange cases performed in our unit between March and July 2020. During the study period, 18 patients with a variety of airway pathologies were successfully managed with transnasal humidified rapid-insufflation ventilatory exchange. For each case, 7-10 staff members were present. Appropriate personal protective equipment protocols were strictly implemented and adhered to. None of the staff involved reported symptoms or tested positive for coronavirus disease 2019, up to at least a month following their exposure to transnasal humidified rapid-insufflation ventilatory exchange. With strictly correct personal protective equipment use, transnasal humidified rapid-insufflation ventilatory exchange can be safely employed for carefully selected patients in the current pandemic, without jeopardising the health and safety of the ENT and anaesthetic workforce.

Performing tracheostomy on COVID-19 pediatric patients at intensive care unit: Our experiences

Background: The novel coronavirus disease-2019 (COVID-19) is posing unprecedented challenges among health-care workers for managing the pediatric tracheostomy. Tracheostomy and posttracheostomy care are considered as high-risk procedures for contamination of health-care workers and other patients of the intensive care unit (ICU) in COVID-19 pandemic.Objective: The objective of this retrospective study is to evaluate the details of pediatric tracheostomy including patients' profile, surgical steps, complications, and precautions by health-care workers at the ICU of the specially assigned hospital for COVID-19 patients.Materials and Methods: This is a descriptive retrospective study in which 18 COVID-19 pediatric patients underwent bedside surgical tracheostomy at the ICU. Clinical patient's profiles such as age, sex, comorbidities, complication of the tracheostomy, ventilator withdrawal after tracheostomy, and nosocomial infections of the health-care professionals related to tracheostomy were analyzed.Results: Of the 18 patients with COVID-19 infections who underwent tracheostomy, there were 11 male (61.11%) and 7 female (38.88%) with a male-to-female ratio being 17:1. The age ranged from 4 years to 18 years, with a mean age of 11.45 years. The mean duration from the day of the orotracheal intubation to the day of tracheostomy was 12 days.Conclusion: Performing surgical tracheostomy on COVID-19 pediatric patients is a high-risk aerosol-generating procedure for health-care professionals. It should be performed with close association with pediatric otolaryngologists, anesthesiologists, and pediatric intensive care physicians along with adequate personal protective equipment for smooth and safe execution of the procedure.

Bedside tracheostomy on COVID-19 patients in the intensive care unit: A retrospective study

Introduction: Currently, coronavirus disease 2019 (COVID-19) infection is a global challenge to the medical community, often resulting in acute respiratory distress syndrome and respiratory failure needing mechanical ventilation. Tracheostomy is needed for prolonged ventilation as the severity of respiratory failure often escalates, needing extended ventilation in an intensive care unit (ICU). Objective: The objective of study was to evaluate clinical details of performing tracheostomy including patient profile, surgical steps, complications and precautions by health-care workers in the ICU of a specially assigned hospital for COVID-19 patients. Patients and Methods: This is a retrospective study of 22 COVID-19 patients who underwent bedside surgical tracheostomy in the ICU. Patient profile such as age, gender, comorbidities, complication of tracheostomy, ventilator withdrawal after tracheostomy and nosocomial infections of health-care workers related to tracheostomy were analysed. Results: In the study period of 6 months, there were 12,850 COVID-19 patients admitted to our COVID-designated hospital, of whom 2452 patients needed ICU care. A total of 610 patients needed ventilatory support, with 22 patients aged between 42 and 75 years (mean age of 64 years) undergoing a tracheostomy (16 males and 6 females). The median duration from the day of the orotracheal intubation to the day of tracheostomy was 13 days. Conclusion: Surgical tracheostomy on COVID-19 patients is a high-risk aerosol-generating procedure for health-care workers. It should be performed with close communication between otorhinolaryngologists, anaesthesiologists and intensivists, along with adequate personal protective equipment for smooth management of the airway.

Rewriting the playbook: infection prevention practices to mitigate nosocomial severe acute respiratory syndrome coronavirus 2 transmission.

Given the limited evidence and experience with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), this novel pathogen has challenged the field of infection prevention. Despite uncertainty, infection prevention principles and experience with similar diseases have helped guide how to best protect providers and patients against disease acquisition. Guidance to date has relied on data from SARS-CoV-1 and MERS-CoV to guide practices on patient isolation and personal protective equipment (PPE) use. Although a face mask and eye protection are likely adequate for most clinical scenarios, published guidelines for PPE can be confusing and conflicting. Consensus for what constitutes a high-risk aerosol-generating procedure (AGP) is lacking, but most agree providers performing procedures such as bronchoscopy, intubation, and cardiopulmonary resuscitation would likely benefit from the use of an N95 respirator and eye protection. Needed research to elucidate the predominant SARS-CoV-2 mode of transmission is not likely to be completed in the immediate future. Recommendations for PPE to mitigate procedure-associated risk remain controversial. Nonetheless, implementation of existing measures based on basic infection prevention principles is likely to prevent transmission significantly.

A quantitative evaluation of aerosol generation during tracheal intubation and extubation.

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.

Overview of Upper Airway Management During COVID-19 Outbreak: Head and Neck Surgeon's Perspective: Comment.

Overview of Upper Airway Management During COVID-19 Outbreak: Head and Neck Surgeon's Perspective: Comment.

Rhinologic Practice Special Considerations During COVID-19: Visit Planning, Personal Protective Equipment, Testing, and Environmental Controls.

As rhinologists return to practice amid SARS-CoV-2, special considerations are warranted given the unique features of their subspecialty. Rhinologist manipulation of nasal tissue, proximity, and frequent aerosol-generating procedures (AGPs) create high risk for infection transmission. There are 4 areas of special consideration to mitigate risk: (1) previsit planning for risk stratification/mitigation, (2) appropriate personal protective equipment, (3) preprocedural testing, and (4) environmental controls. During previsit planning, risk factors of the patient and procedures are considered. High-risk AGPs are identified by duration, proximity, manipulation of high-viral load tissue, and use of powered instrumentation. Appropriate personal protective equipment includes selection of respiratory and eye protection. COVID-19 testing can screen for asymptomatic carriers prior to high-risk procedures; however, alternative testing methods are required in rhinologic patients not eligible for nasopharyngeal testing due to nasal obstruction or skull base defects. Last, AGPs in rhinologic practices require considerations of room air handling and environmental controls.

Otolaryngology in the Time of Corona: Assessing Operative Impact and Risk During the COVID-19 Crisis.

ObjectiveLimited research exists on the coronavirus disease 2019 (COVID-19) pandemic pertaining to otolaryngology–head and neck surgery (OHNS). The present study seeks to understand the response of OHNS workflows in the context of policy changes and to contribute to developing preparatory guidelines for perioperative management in OHNS.Study DesignRetrospective cohort study.SettingPediatric and general adult academic medical centers and a Comprehensive Cancer Center (CCC).Subjects and MethodsOHNS cases from March 18 to April 8, 2020—the 3 weeks immediately following the Ohio state-mandated suspension of all elective surgery on March 18, 2020—were compared with a 2019 control data set.ResultsDuring this time, OHNS at the general adult and pediatric medical centers and CCC experienced 87.8%, 77.1%, and 32% decreases in surgical procedures as compared with 2019, respectively. Aerosol-generating procedures accounted for 86.8% of general adult cases, 92.4% of pediatric cases, and 62.0% of CCC cases. Preoperative COVID-19 testing occurred in 7.1% of general adult, 9% of pediatric, and 6.9% of CCC cases. The majority of procedures were tiers 3a and 3b per the Centers for Medicare & Medicaid Services. Aerosol-protective personal protective equipment (PPE) was worn in 28.6% of general adult, 90% of pediatric, and 15.5% of CCC cases.ConclusionFor OHNS, the majority of essential surgical cases remained high-risk aerosol-generating procedures. Preoperative COVID-19 testing and intraoperative PPE usage were initially inconsistent; systemwide guidelines were developed rapidly but lagged behind recommendations of the OHNS department and its academy. OHNS best practice standards are needed for preoperative COVID-19 status screening and PPE usage as we begin national reopening.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.