Personal protective equipment (PPE) for both anesthesiologists and other airway managers: principles and practice during the COVID-19 pandemic

Abstract

Healthcare providers are facing a coronavirus disease pandemic. This pandemic may last for many months, stressing the Canadian healthcare system in a way that has not previously been seen. Keeping healthcare providers safe, healthy, and available to work throughout this pandemic is critical. The consistent use of appropriate personal protective equipment (PPE) will help assure its availability and healthcare provider safety. The purpose of this communique is to give both anesthesiologists and other front-line healthcare providers a framework from which to understand the principles and practices surrounding PPE decision-making. We propose three types of PPE including: 1) PPE for droplet and contact precautions, 2) PPE for general airborne, droplet, and contact precautions, and 3) PPE for those performing or assisting with high-risk aerosol-generating medical procedures.

Keywords: COVID-19; coronavirus; personal protective equipment.

Figure 1

Droplets vs airborne particles (also called droplet nuclei). 1. Large infectious droplets. These droplets are generally > 60 µm in diameter. Toilet water is noted here as severe acute respiratory syndrome coronavirus was shown to aerosolize in toilet water. 2. Small infectious droplets. These droplets are generally 10-60 µm in diameter. 3. Infectious droplet nuclei, also called airborne particles, are generally < 10 µm in diameter. Coughing and sneezing tend to produce a spectrum of droplets, that vary in mean droplet size and number. For example, sneezing produces 4,000-4,600 droplets whereas coughing produces a few hundred droplets. Room humidity, temperature, and air changes per hour contribute to determining droplet size. Viral load and initial mean and distribution size of droplets are determined by the patient. Used with permission of the British Columbia (BC) Provincial Health Services Authority (BC Centre for Disease Control).

Figure 2

Decision-making for appropriate PPE in COVID-19 for anesthesiologists and other airway managers. The decision as to the most appropriate personal protective equipment (PPE) to use in COVID-19 patients is based on the clinical care being undertaken. For care not involving high-risk aerosol-generating medical procedures (AGMP), use droplet and contact precautions, which include a surgical mask with face-shield, Association for the Advancement of Medical Instrumentation (AAMI)-level 2 gown, and single gloves, as shown in panel A (used with permission from Lockhart et al.). For a healthcare provider present in the room during an AGMP, use airborne, droplet, and contact precautions which include an N95 respirator, eye shield, head covering, AAMI level-2 gown, and single gloves, as in panel B. If you are performing (or directly assisting in) the AGMP itself, then airborne, droplet, and contact precautions should be worn that additionally include a AAMI level-3 gown, neck cover, and 2 pairs of gloves (both panels C and D are considered equivalent levels of PPE)