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Coughs and Sneezes Spread Diseases

Claire NESTOR¹, Stephen WANG², Michael IRWIN^1
1Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong, ² Department of Mechanical Engineering, City University of Hong Kong, Hong Kong

Background: The COVID-19 pandemic has significantly impacted peri-operative care of patients.  There is evidence that airway management may be a source of transmission of infection as these are potential aerosol-generating procedures (AGPs) and, therefore, use of full airborne personal protective equipment (PPE) has become standard practice in all patients. Recommendations are revised periodically and, given the rapid escalation of the pandemic, often have little evidence base, thereby adding to the cognitive load and anxiety of frontline healthcare workers there. Current infection control guidelines are based more on a precautionary than evidential approach.

Method: We reviewed recently published literature with robust scientific approaches to evaluate aerosol generation during tracheal intubation and extubation to address this gap in evidence.

Results: Tracheal intubation and extubation produce a certain number of aerosols which can remain suspended and spread in the operation room air. Low background concentration levels facilitated the detection of changes that occurred during typical airway management. A single volitional cough produced more aerosols than the sequence of intubation or extubation.

Conclusion: Aerosol generation has been a major focus of guidelines underpinning the required level of PPE. It is imperative to recognise that many daily activities generate aerosols, but these do not necessitate staff to don the same high level of PPE.  We propose risk stratification and the PPE level required could be determined based on TOCC (Travel, Occupation, Contact, Cluster) history, whether patients are symptomatic of infection and test results (Table 1).

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