Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to Healthcare Workers: A Systematic Review

Abstract

Aerosol generating procedures (AGPs) may expose health care workers (HCWs) to pathogens causing acute respiratory infections (ARIs), but the risk of transmission of ARIs from AGPs is not fully known. We sought to determine the clinical evidence for the risk of transmission of ARIs to HCWs caring for patients undergoing AGPs compared with the risk of transmission to HCWs caring for patients not undergoing AGPs. We searched PubMed, EMBASE, MEDLINE, CINAHL, the Cochrane Library, University of York CRD databases, EuroScan, LILACS, Indian Medlars, Index Medicus for SE Asia, international health technology agencies and the Internet in all languages for articles from 01/01/1990 to 22/10/2010. Independent reviewers screened abstracts using pre-defined criteria, obtained full-text articles, selected relevant studies, and abstracted data. Disagreements were resolved by consensus. The outcome of interest was risk of ARI transmission. The quality of evidence was rated using the GRADE system. We identified 5 case-control and 5 retrospective cohort studies which evaluated transmission of SARS to HCWs. Procedures reported to present an increased risk of transmission included [n; pooled OR(95%CI)] tracheal intubation [n = 4 cohort; 6.6 (2.3, 18.9), and n = 4 case-control; 6.6 (4.1, 10.6)], non-invasive ventilation [n = 2 cohort; OR 3.1(1.4, 6.8)], tracheotomy [n = 1 case-control; 4.2 (1.5, 11.5)] and manual ventilation before intubation [n = 1 cohort; OR 2.8 (1.3, 6.4)]. Other intubation associated procedures, endotracheal aspiration, suction of body fluids, bronchoscopy, nebulizer treatment, administration of O2, high flow O2, manipulation of O2 mask or BiPAP mask, defibrillation, chest compressions, insertion of nasogastric tube, and collection of sputum were not significant. Our findings suggest that some procedures potentially capable of generating aerosols have been associated with increased risk of SARS transmission to HCWs or were a risk factor for transmission, with the most consistent association across multiple studies identified with tracheal intubation.

Infection Prevention and Control Guideline for Cystic Fibrosis: 2013 Update

“…112,113 Since publication of the 2003 Infection Control Guideline for CF, several studies conducted in people with and without CF who are infected with viral or bacterial pathogens have expanded our understanding of droplet transmission and now challenge the 3-foot rule. These studies include epidemiologic data collected during outbreaks of influenza 114,115 and SARS in non-CF individuals, [116][117][118] experimental and observational studies performed in people with CF, [119][120][121] and studies of the dynamics of infectious aerosols. 119,122,123 …”

“…Infectious droplets containing influenza virus and SARS-CoV traveled 3-6 feet. 6,114,116,118 Aerosols of droplet nuclei from patients infected with influenza can be generated during intubation and suctioning. Droplet size and distance traveled can be affected by (1) environmental factors (eg, humidity, temperature, air currents, and number of air changes per hour in a room), (2) agent factors (eg, infectious load, transferability, survivability, infectivity, and contagiousness), and (3) host factors (eg, susceptibility and behavior).…”

A Cost Analysis of Salbutamol Administration by Metered-Dose Inhalers with Spacers versus Nebulization for Patients with Wheeze in the Pediatric Emergency Department: Evidence from Observational Data in Nova Scotia

“…2 MDI-s also result in increased child and parent treatment satisfaction and may reduce staff and caregiver risk during respiratory infection epidemics. [3][4][5] Although PEDs in Canada are now accepting MDI-s as the route of choice for salbutamol inhalation, 6 one of the factors linked to resistance to switching salbutamol inhalation methods is the perception of increased costs. 7,8 The cost-effectiveness of MDI-s versus NEB has been documented, 4,[9][10][11][12] but no published Canadian study has used local clinical and administrative data in their analysis.…”

Communicating the Changing Role of a Nurse in an Epidemic: The Example of the MERS-CoV Outbreak in Saudi Arabia

“…Having a large surge of very ill patients puts a stress on the entire health care system. Also, many of the procedures that nurses initiate (such as deep breathing and coughing, assisting with bronchoscopy, intubation/ extubation cardiopulmonary resuscitation, taking sputum samples, and suctioning) may be the method of aerosolization of coronavirus [11].…”