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Quantifying Viral Particle Aerosolization Risk During Tracheostomy Surgery and Tracheostomy Care.
JAMA Otolaryngol Head Neck Surg. 2021 09 01; 147(9):797-803.JO

Abstract

Importance

During respiratory disease outbreaks such as the COVID-19 pandemic, aerosol-generating procedures, including tracheostomy, are associated with the risk of viral transmission to health care workers.

Objective

To quantify particle aerosolization during tracheostomy surgery and tracheostomy care and to evaluate interventions that minimize the risk of viral particle exposure.

Design, Setting, and Participants

This comparative effectiveness study was conducted from August 2020 to January 2021 at a tertiary care academic institution. Aerosol generation was measured in real time with an optical particle counter during simulated (manikin) tracheostomy surgical and clinical conditions, including cough, airway nebulization, open suctioning, and electrocautery. Aerosol sampling was also performed during in vivo swine tracheostomy procedures (n = 4), with or without electrocautery. Fluorescent dye was used to visualize cough spread onto the surgical field during swine tracheostomy. Finally, 6 tracheostomy coverings were compared with no tracheostomy covering to quantify reduction in particle aerosolization.

Main Outcomes and Measures

Respirable aerosolized particle concentration.

Results

Cough, airway humidification, open suctioning, and electrocautery produced aerosol particles substantially above baseline. Compared with uncovered tracheostomy, decreased aerosolization was found with the use of tracheostomy coverings, including a cotton mask (73.8% [(95% CI, 63.0%-84.5%]; d = 3.8), polyester gaiter 79.5% [95% CI, 68.7%-90.3%]; d = 7.2), humidification mask (82.8% [95% CI, 72.0%-93.7%]; d = 8.6), heat moisture exchanger (HME) (91.0% [95% CI, 80.2%-101.7%]; d = 19.0), and surgical mask (89.9% [95% CI, 79.3%-100.6%]; d = 12.8). Simultaneous use of a surgical mask and HME decreased the particle concentration compared with either the HME (95% CI, 1.6%-12.3%; Cohen d = 1.2) or surgical mask (95% CI, 2.7%-13.2%; d = 1.9) used independently. Procedures performed with electrocautery increased total aerosolized particles by 1500 particles/m3 per 5-second interval (95% CI, 1380-1610 particles/m3 per 5-second interval; d = 1.8).

Conclusions and Relevance

The findings of this laboratory and animal comparative effectiveness study indicate that tracheostomy surgery and tracheostomy care are associated with significant aerosol generation, putting health care workers at risk for viral transmission of airborne diseases. Combined HME and surgical mask coverage of the tracheostomy was associated with decreased aerosolization, thereby reducing the risk of viral transmission to health care workers.

Authors+Show Affiliations

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.Johns Hopkins University School of Medicine, Baltimore, Maryland.Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor.Department of Nursing Faculty, and Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland.Department of Environmental Health and Engineering, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

34292321

Citation

Berges, Alexandra J., et al. "Quantifying Viral Particle Aerosolization Risk During Tracheostomy Surgery and Tracheostomy Care." JAMA Otolaryngology-- Head & Neck Surgery, vol. 147, no. 9, 2021, pp. 797-803.
Berges AJ, Lina IA, Ospino R, et al. Quantifying Viral Particle Aerosolization Risk During Tracheostomy Surgery and Tracheostomy Care. JAMA Otolaryngol Head Neck Surg. 2021;147(9):797-803.
Berges, A. J., Lina, I. A., Ospino, R., Tsai, H. W., Brenner, M. J., Pandian, V., Rule, A. M., & Hillel, A. T. (2021). Quantifying Viral Particle Aerosolization Risk During Tracheostomy Surgery and Tracheostomy Care. JAMA Otolaryngology-- Head & Neck Surgery, 147(9), 797-803. https://doi.org/10.1001/jamaoto.2021.1383
Berges AJ, et al. Quantifying Viral Particle Aerosolization Risk During Tracheostomy Surgery and Tracheostomy Care. JAMA Otolaryngol Head Neck Surg. 2021 09 1;147(9):797-803. PubMed PMID: 34292321.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Quantifying Viral Particle Aerosolization Risk During Tracheostomy Surgery and Tracheostomy Care. AU - Berges,Alexandra J, AU - Lina,Ioan A, AU - Ospino,Rafael, AU - Tsai,Hsiu-Wen, AU - Brenner,Michael J, AU - Pandian,Vinciya, AU - Rule,Ana M, AU - Hillel,Alexander T, PY - 2022/07/22/pmc-release PY - 2021/7/23/pubmed PY - 2021/7/23/medline PY - 2021/7/22/entrez SP - 797 EP - 803 JF - JAMA otolaryngology-- head & neck surgery JO - JAMA Otolaryngol Head Neck Surg VL - 147 IS - 9 N2 - Importance: During respiratory disease outbreaks such as the COVID-19 pandemic, aerosol-generating procedures, including tracheostomy, are associated with the risk of viral transmission to health care workers. Objective: To quantify particle aerosolization during tracheostomy surgery and tracheostomy care and to evaluate interventions that minimize the risk of viral particle exposure. Design, Setting, and Participants: This comparative effectiveness study was conducted from August 2020 to January 2021 at a tertiary care academic institution. Aerosol generation was measured in real time with an optical particle counter during simulated (manikin) tracheostomy surgical and clinical conditions, including cough, airway nebulization, open suctioning, and electrocautery. Aerosol sampling was also performed during in vivo swine tracheostomy procedures (n = 4), with or without electrocautery. Fluorescent dye was used to visualize cough spread onto the surgical field during swine tracheostomy. Finally, 6 tracheostomy coverings were compared with no tracheostomy covering to quantify reduction in particle aerosolization. Main Outcomes and Measures: Respirable aerosolized particle concentration. Results: Cough, airway humidification, open suctioning, and electrocautery produced aerosol particles substantially above baseline. Compared with uncovered tracheostomy, decreased aerosolization was found with the use of tracheostomy coverings, including a cotton mask (73.8% [(95% CI, 63.0%-84.5%]; d = 3.8), polyester gaiter 79.5% [95% CI, 68.7%-90.3%]; d = 7.2), humidification mask (82.8% [95% CI, 72.0%-93.7%]; d = 8.6), heat moisture exchanger (HME) (91.0% [95% CI, 80.2%-101.7%]; d = 19.0), and surgical mask (89.9% [95% CI, 79.3%-100.6%]; d = 12.8). Simultaneous use of a surgical mask and HME decreased the particle concentration compared with either the HME (95% CI, 1.6%-12.3%; Cohen d = 1.2) or surgical mask (95% CI, 2.7%-13.2%; d = 1.9) used independently. Procedures performed with electrocautery increased total aerosolized particles by 1500 particles/m3 per 5-second interval (95% CI, 1380-1610 particles/m3 per 5-second interval; d = 1.8). Conclusions and Relevance: The findings of this laboratory and animal comparative effectiveness study indicate that tracheostomy surgery and tracheostomy care are associated with significant aerosol generation, putting health care workers at risk for viral transmission of airborne diseases. Combined HME and surgical mask coverage of the tracheostomy was associated with decreased aerosolization, thereby reducing the risk of viral transmission to health care workers. SN - 2168-619X UR - https://www.unboundmedicine.com/medline/citation/34292321/Quantifying_Viral_Particle_Aerosolization_Risk_During_Tracheostomy_Surgery_and_Tracheostomy_Care. L2 - https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/10.1001/jamaoto.2021.1383 DB - PRIME DP - Unbound Medicine ER -