COVID-19 Droplet and Airborne Precautions
For healthcare workers performing aerosol-generating procedures on COVID-19 patients, fitted respirator masks (N95, FFP2, or equivalent) must be used along with other personal protective equipment (gloves, gown, and eye protection) to minimize transmission risk.
Personal Protective Equipment Recommendations
For Aerosol-Generating Procedures
- Fitted respirator masks (N95, FFP2, or equivalent) are required for healthcare workers performing aerosol-generating procedures on COVID-19 patients 1
- Complete PPE should include gloves, gown, and eye protection (face shield or safety goggles) in addition to respirator masks 1
- Aerosol-generating procedures should be performed in negative pressure rooms 1
- Common aerosol-generating procedures include: endotracheal intubation, bronchoscopy, open suctioning, nebulized treatment administration, manual ventilation before intubation, physical proning, disconnecting patients from ventilators, non-invasive positive pressure ventilation, tracheostomy, and cardiopulmonary resuscitation 1
For Non-Aerosol-Generating Procedures
- For healthcare workers providing usual care for non-ventilated COVID-19 patients, surgical/medical masks are suggested along with other PPE (gloves, gown, eye protection) 1
- For healthcare workers performing non-aerosol-generating procedures on mechanically ventilated (closed circuit) patients, surgical/medical masks are suggested with other PPE 1
- Patients should wear surgical masks to prevent droplet transmission 1
Respirator Specifications and Selection
- N95 respirators conform to US FDA standards while FFP2 conforms to European standards, both designed to block 95-99% of aerosol particles 1
- Staff should be fit-tested for each different type of respirator to ensure proper protection 1
- Surgical masks are less effective than respirators in blocking small particle aerosols (<5 μm) 1
- Powered air purifying respirators (PAPRs) can be used by healthcare workers who failed N95 mask fit testing or when N95s are in limited supply 1
- High-risk procedures may warrant enhanced respiratory protection with filters certified as 99,100, or HEPA (high-efficiency particulate air) 2
Room Requirements and Environment
- Aerosol-generating procedures should be performed in negative pressure rooms 1
- Negative pressure prevents accidental release of pathogens into larger spaces and open facilities 1
- When negative pressure rooms are unavailable, operating rooms with high air exchange rates (minimum 15 exchanges per hour) can be used, which remove 99% of airborne contaminants in 18 minutes 1
- If positive pressure rooms must be used, consider decreasing inflow while increasing exhaust to maintain neutral pressure while preserving laminar flow over surgical areas 1
Procedural Considerations
- For endotracheal intubation, video-guided laryngoscopy is preferred over direct laryngoscopy when available 1
- Intubation should be performed by the most experienced healthcare worker to minimize attempts and transmission risk 1
- For regional anesthesia procedures (not considered aerosol-generating), droplet precautions are recommended as minimum protection 1
- General anesthesia is recommended for patients with suspected or confirmed COVID-19 to reduce the risk of coughing and bucking 1
- Rapid sequence induction should be used after complete PPE checks for all personnel in the operating room 1
Special Considerations
- Initial fit pass rates for respirators vary between 40-90% and are especially low in female and Asian healthcare workers 3
- Fit checking (self-test) should be performed each time a healthcare worker dons a respirator, but is not reliable alone for detecting proper fit 3
- For cardiac arrest management, minimize the number of personnel in the room and ensure proper PPE for all team members 1
- Consider the potential need for conversion to general anesthesia when selecting PPE for procedures initially planned under regional anesthesia 1
Common Pitfalls and Caveats
- Respirator masks must be properly fit-tested to provide adequate protection - a poorly fitted N95 may not provide better protection than a surgical mask 3
- Reuse of disposable N95 masks during shortages should follow institutional protocols for safe handling and storage 4
- Elastomeric respirators may be considered as sustainable alternatives to disposable N95 masks during shortages 4
- Airborne precautions should be maintained for the appropriate duration based on room air exchanges after aerosol-generating procedures are completed 1
- The most experienced personnel should perform high-risk procedures to minimize duration and number of attempts 1