key: cord-0711563-ag1ipdte
authors: Jarvis, Jeffrey L.; Gonzales, John
title: What is the real risk of COVID transmission during oxygenation?
date: 2021-06-18
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12457
sha: 5b6f43e14d8c35265aa0076e1a5b5767828bb64b
doc_id: 711563
cord_uid: ag1ipdte

nan

Recently, I was called up to the intensive care unit (ICU) to intubate a hypoxic patient with coronavirus disease (COVID). Walking into the patient's room, I noted lots of people in personal protective equipment (PPE), most of whom I knew to be fully vaccinated. The patient was, indeed, hypoxic on high flow nasal cannula (HFNC). Could we put him on bi-level positive airway pressure (BiPAP) for better pre-oxygenation before rapid sequence intubation (RSI)? Nope. Hospital policy prevented the use of BiPAP (but not HFNC) on COVID patients. So, we had to accept sub-optimal pre-oxygenation because of a policy understandably designed to protect staff but that was not in the patient's best interest. Experiences like this really beg several important clini- Finally, they placed a procedural mask over the HFNC and NRB to evaluate the impact of the common approach of mask-over-oxygen device. Ultimately, they demonstrated that higher flow oxygen led to higher aerosol generation, and CPAP was actually associated with lower aerosol generation. Masks were helpful for reduction of small particulates but not with larger ones, at least not statistically with only 8 subjects. These findings help us understand that CPAP is actually relatively low risk, certainly less than HFNC, and placing a mask over the devices may help lower exposure risk.

So, we now have more information about aerosol generation, but what about the extent to which PPE protects us against infection?

Dr. Darren Braude and colleagues looked at this with a pragmatic approach. In their paper "Safety of air medical transport of patients with COVID-19 by personnel using routine personal protective equipment" they used an 8-base regional air medical consortium to describe the rate of infection among transport personnel after flying patients with COVID. 2 Taken together, these 2 papers provide additional information we can use to guide our approach to caring for COVID patients with respiratory distress while still protecting ourselves and our colleagues. It appears that CPAP is a relatively low risk approach to respiratory support, certainly it looks like a lower risk than HFNC or NRB. In addition, we have additional reassurance that the PPE we are using provides substantial protection against infection.

Aerosol generation with various approaches to oxygenation in healthy volunteers in the emergency department

Safety of air medical transport of patients with COVID-19 by personnel using routine personal protective equipment

Occupational Exposures and Programmatic Response to COVID-19 Pandemic: An Emergency Medical Services Experience

What is the real risk of COVID transmission during oxygenation?