Does COVID-19 (Coronavirus Disease 2019) require only droplet precautions or both droplet and respiratory precautions?

COVID-19 Transmission Precautions: Droplet and Airborne

COVID-19 requires both droplet and airborne precautions for optimal protection of healthcare workers and patients, as the virus can be transmitted through both mechanisms depending on the clinical context. 1

Transmission Routes

• COVID-19 is primarily transmitted through respiratory droplets and contact routes, but airborne transmission is also possible, particularly during aerosol-generating procedures 2
• Traditional distinction between droplet and airborne transmission has been questioned during the pandemic, as evidence suggests SARS-CoV-2 can travel beyond the conventional 1-2 meter droplet range 3
• Studies have shown that droplets can travel more than 2 meters, in some cases up to 8 meters, challenging the standard spatial separation guidelines 3

Required Precautions Based on Clinical Scenario

Standard Patient Care (Non-Aerosol Generating)

• For routine care of COVID-19 patients without aerosol-generating procedures, droplet precautions are recommended as a minimum 4
• This includes:
  • Surgical/medical mask
  • Eye protection (face shield or goggles)
  • Gown
  • Gloves 1
• Patients should wear surgical facemasks to prevent droplet transmission 4

Aerosol-Generating Procedures

• For aerosol-generating procedures, airborne precautions are required 1
• This includes:
  • Fitted respirator masks (N95, FFP2, or equivalent)
  • Eye protection (face shield or goggles)
  • Gown
  • Gloves 1
• Common aerosol-generating procedures include:
  • Endotracheal intubation
  • Bronchoscopy
  • Open suctioning
  • Administration of nebulized treatment
  • Non-invasive positive pressure ventilation
  • Cardiopulmonary resuscitation 1, 2

Environmental Controls

• Aerosol-generating procedures should ideally be performed in negative pressure rooms 1
• When negative pressure rooms are unavailable, operating rooms with high air exchange rates can be used, which remove 99% of airborne contaminants in approximately 18 minutes 1
• Adequate ventilation is crucial for reducing airborne transmission risk in indoor environments 5

Procedural Considerations

• The most experienced healthcare worker should perform high-risk procedures to minimize duration and number of attempts 1
• For procedures initially planned under regional anesthesia, consider the potential need for conversion to general anesthesia when selecting PPE 1
• Oxygen therapy should be administered with caution, as the flow rate and delivery method can affect aerosol generation 4
• The flow of oxygen should be kept to a minimum while maintaining adequate saturation 4

Common Pitfalls and Practical Recommendations

• Don't assume that droplet precautions alone are sufficient for all COVID-19 patient interactions - the context matters 3
• Don't underestimate the risk from asymptomatic carriers who can still shed virus and produce infectious droplets 2
• Don't forget that airborne precautions should be maintained for the appropriate duration based on room air exchanges after aerosol-generating procedures are completed 1
• Remember that the distinction between procedures requiring droplet vs. airborne precautions is not always clear-cut, so err on the side of caution in ambiguous situations 6

Special Considerations

• For regional anesthesia procedures, which are not considered aerosol-generating, droplet precautions are recommended as a minimum, but higher-level precautions may be appropriate in certain situations 4
• The use of respirator masks (N95 or FFP2/3) may be considered for prolonged close contact with a COVID-19 patient in a closed environment, even for non-aerosol-generating procedures 4
• Engineering controls in buildings, including sufficient ventilation, particle filtration, and avoiding air recirculation, can help reduce transmission risk 5