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Clinical Evidence Based Review and Recommendations of Aerosol

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Clinical Evidence Based Review and Recommendations of Aerosol Thamboo et al. Journal of Otolaryngology - Head and Neck Surgery (2020) 49:28 https://doi.org/10.1186/s40463-020-00425-6 REVIEW Open Access Clinical evidence based review and recommendations of aerosol generating medical procedures in otolaryngology – head and neck surgery during the COVID- 19 pandemic Andrew Thamboo1*, Jane Lea1, Doron D. Sommer2, Leigh Sowerby3, Arman Abdalkhani1, Christopher Diamond1, Jennifer Ham4, Austin Heffernan4, M. Cai Long4, Jobanjit Phulka4,YuQiWu4, Phillip Yeung4 and Marc Lammers1 Abstract Background: Aerosol generating medical procedures (AGMPs) present risks to health care workers (HCW) due to airborne transmission of pathogens. During the COVID-19 pandemic, it is essential for HCWs to recognize which procedures are potentially aerosolizing so that appropriate infection prevention precautions can be taken. The aim of this literature review was to identify potential AGMPs in Otolaryngology - Head and Neck Surgery and provide evidence-based recommendations. Methods: A literature search was performed on Medline, Embase and Cochrane Review databases up to April 3, 2020. All titles and abstracts of retrieved studies were evaluated and all studies mentioning potential AGMPs were included for formal review. Full text of included studies were assessed by two reviewers and the quality of the studies was evaluated. Ten categories of potential AGMPs were developed and recommendations were provided for each category. Results: Direct evidence indicates that CO2 laser ablation, the use of high-speed rotating devices, electrocautery and endotracheal suctioning are AGMPs. Indirect evidence indicates that tracheostomy should be considered as potential AGMPs. Nasal endoscopy and nasal packing/epistaxis management can result in droplet transmission, but it is unknown if these procedures also carry the risk of airborne transmission. Conclusions: During the COVID-19 pandemic, special care should be taken when CO2 lasers, electrocautery and high-speed rotating devices are used in potentially infected tissue. Tracheal procedures like tracheostomy and endotracheal suctioning can also result in airborne transmission via small virus containing aerosols. Keywords: COVID-19, Aerosol, Guideline, Aerosolization, Review * Correspondence: [email protected] 1Division of Otolaryngology Head & Neck Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Thamboo et al. Journal of Otolaryngology - Head and Neck Surgery (2020) 49:28 Page 2 of 14 Background that pertained to the realm of the head and neck region. In the era of globalization, infectious disease outbreaks All abstracts were reviewed and the following inclusion have brought unprecedented challenges to the medical criteria was applied: English articles, clinical or experi- community. Coronavirus disease 2019 (COVID-19), the mental studies involving procedures in the head and clinical condition caused by infection with severe acute re- neck region. Studies were excluded if they were opinion spiratory syndrome coronavirus 2 (SARS-CoV-2), rapidly papers, review papers, or if only the abstract was pub- became the world’s 6th public health emergency of inter- lished (no manuscript available). This first review of pa- national concern (PHEIC) declared by the World Health pers led to the following procedures being identified: Organization since 2009 [1]. The other PHEICs were the nasal endoscopy, nasal packing and treatment of epi- swine flu in 2009, polio in 2014, Ebola virus in 2014 and staxis, endoscopic sinonasal and anterior skull base sur- 2018–20, and Zika virus in 2016 [1]. SARS, small pox and gery, CO2 laser ablation, electrocautery, tracheotomy, wild type poliomyelitis are automatic PHEICs and do not endotracheal suctioning, oropharyngeal surgery, head require declaration from the WHO [2]. and neck reconstruction surgery, dental procedures, Although the main environmental route of transmis- mastoid surgery and nebulizer/atomizer. A second fo- sion of SARS-CoV-2 is through droplets and formites/ cused literature search was performed for each of the surfaces, there is a potential risk of virus spread in aforementioned procedures using the search term (aero- smaller aerosols during various medical procedures caus- sol* or droplet*) and the synonyms of the procedure (e.g. ing airborne transmission [3–6]. “Airborne transmission” (aerosol or droplet) and (mastoidectomy or mastoid* or refers to transmission of infection via small (< 5-10um) mastoid surgery)). The same inclusion and exclusion cri- inspirable aerosols over extensive distances, whereas teria were applied except this time procedures that were “droplet transmission” refers to transmission of infection in the head and neck region but not performed by an by (larger) aerosols over short distances directly from the Otolaryngologist were removed (example: irrigation infected person to the susceptible person [7, 8]. wash in dental procedure). This was done in order to en- Various procedures performed by Otolaryngologists to sure no further articles were missed on the first search assess and/or treat patients may generate aerosols from and to keep articles chosen were relevant to the audi- areas of high viral shedding, such as the nasal and oral- ence of interest. Review papers were also cross refer- pharyngeal cavity [6, 9]. Such aerosol generating medical enced to ensure all studies were identified. procedures (AGMPs) can lead to close proximity trans- The included articles were categorized into various po- mission of aerosols, but also in the spread of small aero- tential AGMP procedures. In this review an AGMP is de- sols over extensive distances resulting in airborne fined as a medical procedure which has the potential to transmission. According to colleagues in other countries generate small (< 5-10um) aerosols that can travel greater such as China, Italy, and Iran, Otolaryngologists are than 2 m, and therefore an AGMP confers the potential for among the highest risk group of contracting viruses airborne transmission. In contrast, we defined droplet while performing upper airway procedures without ap- transmission as involving (larger) aerosols over short dis- propriate Personal Protective Equipment (PPE) [10]. As tances (< 2 m) directly from the infected person to the sus- there is worldwide limited availability of PPE, it is essen- ceptible person via mechanisms such as coughing and tial to distinguish which procedures justify the use of sneezing. Each AGMP procedure category was assigned to high level, airborne precautions. The objective of this a practicing Otolaryngologist Head & Neck Surgeon to re- literature review is to identify potential AGMPs in viewtheevidencefoundinthearticles,gradetheevidence Otolaryngology - Head and Neck Surgery (OHNS) and of the articles and develop recommendations for practice. provide evidence-based recommendations. The recommendations were created based on study design, the quality of research, directness of evidence and finally Methods the balance between the potential harm of the procedure This manuscript followed the published methodology of and the quality of evidence [12]. Since the potential harm developing an evidence-based review with recommenda- of aerosolizing viable pathogens can have a large impact on tions by Rudmik et al. (2011) [11]. A literature search the safety of HCWs, a strong recommendation can still be was performed on Medline, Embase and Cochrane Re- warranted despite low or very low confidence in effect esti- view Databases from inception to April 3, 2020. Given mates [12]. Direct and high quality evidence was defined as aerosol and droplet terminology has been used inter- studies evaluating directly, or indirectly particles/aerosol changeably in the literature, the search included both concentrations in air samples. Indirect evidence could be terms. A screening literature search was first performed obtained from experimental cadaver models, or retrospect- using the search term (aerosol* or droplet*) and (proced- ive epidemiological data. The manuscript then underwent ure or treatment or surgery). The authors, J.H., A.H., an iterative review process in the following order: M. L, C.L., J. P, YWQ, and P.Y. reviewed the articles for topics C.D., J.L., D.D.S., L. S and A.T. Thamboo et al. Journal of Otolaryngology - Head and Neck Surgery (2020) 49:28 Page 3 of 14 Results nare
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