Which surgeries require extra PPE? New review rounds up international guidance

Canadian scientists participated in what they believe to be the first systematic and international survey this spring looking at guidance on aerosol-generating medical procedures.

There is consensus among experts for some types of procedures, but not all

Heath-care workers wear N95 respirators and other forms of personal protective equipment when handling patients undergoing aerosol-generating medical procedures. (Guy Leblanc/Radio-Canada)

In terms of COVID-19 transmission, some medical procedures are riskier for health-care workers than others, but a new international review reveals that experts do not always agree on which ones.

In what they believe was the first systematic and international survey of guidance on aerosol-generating procedures, researchers from the University of Alberta, the University of Toronto, the University of Oxford and the University of Limerick reviewed guidelines, policy documents and academic papers about aerosol-generating procedures during March and April of this year.

The team analyzed French and English-language documents from nine countries — most came from Canada — with a goal to determine which medical procedures were classified as aerosol-generating and which were not.

The distinction is important because aerosol-generating medical procedures, or AGMPs, can induce tiny droplets of infectious liquid. Those aerosols can linger in the air, putting health-care workers at a greater risk of becoming infected with COVID-19.

Because of this heightened risk, health authorities and governments have paired these procedures with extra precautions like N95 respirators and isolation rooms.

Consensus on some procedures

The researchers' findings, which were published in the peer-reviewed journal BMJ Open Respiratory Research last week, concluded that sufficient evidence exists to classify at least 19 procedure groups as aerosol-generating.

"We have a high level of confidence that, yes, these procedures are capable of generating aerosols and therefore that appropriate protective measures should be undertaken," said Dr. Sebastian Straube. 

Straube, who led the review, is a professor of medicine in the University of Alberta's faculty of medicine and dentistry and director of its preventive medicine division.

Straube's team found the types of procedures most often classified as aerosol-generating included intubation and extubation, airway suctioning, bronchoscopy and sputum induction.

Less consensus on other procedures

There was less consensus elsewhere, however. 

Certain procedures were classified differently across documents, with some experts labelling them as aerosol-generating and others saying they weren't. These included oral and dental procedures, upper gastrointestinal endoscopy, thoracic surgery and oropharyngeal swabbing.

The disagreements and inconsistencies could provide opportunities for further study.

"Clearly, where there is disagreement among the experts, there's a need to look at more detail and think about why there might be disagreement and resolve that," Straube said Tuesday in an interview with CBC Edmonton's Radio Active.

The researchers recommend policymakers take the review's findings into account when creating or updating guidelines for patients, health-care workers and other individuals present for medical procedures.

Straube, who is a member of the World Health Organization's Evidence Collaborative for COVID-19, said he shared the paper's findings with that network as well as with Alberta Health Services.

"There certainly is interest and I remain hopeful that it will be taken into consideration," he said.


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