The protective effect of tight-fitting powered air-purifying respirators during chest compressions

https://doi.org/10.1016/j.ajem.2021.06.012Get rights and content

Highlights

  • •

    Powered air-purifying respirators (PAPRs) is a type of personal protective equipment.

  • •

    We measured the protective effect of tight-fitting PAPRs during chest compressions.

  • •

    Tight-fitting PAPR did not provide adequate protection during chest compression.

Abstract

Background

Airborne personal protective equipment is required for healthcare workers when performing aerosol-generating procedures on patients with infectious diseases. Chest compressions, one of the main components of cardiopulmonary resuscitation, require intense and dynamic movements of the upper body. We aimed to investigate the protective effect of tight-fitting powered air-purifying respirators (PAPRs) during chest compressions.

Methods

This single-center simulation study was performed from February 2021 to March 2021. The simulated workplace protection factor (SWPF) is the concentration ratio of ambient particles and particles inside the PAPR mask; this value indicates the level of protection provided by a respirator when subjected to a simulated work environment. Participants performed continuous chest compressions three times for 2 min each time, with a 4-min break between each session. We measured the SWPF of the tight-fitting PAPR during chest compression in real-time mode. The primary outcome was the ratio of any failure of protection (SWPF <500) during the chest compression sessions.

Results

Fifty-four participants completed the simulation. Overall, 78% (n = 42) of the participants failed (the measured SWPF value was less than 500) at least one of the three sessions of chest compressions. The median value and interquartile range of the SWPF was 4304 (685–16,191). There were no reports of slipping down of the respirator or mechanical failure during chest compressions.

Conclusions

Although the median SWPF value was high during chest compressions, the tight-fitting PAPR did not provide adequate protection.

Introduction

The novel coronavirus disease 2019 (COVID-19) is a disease caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus which appeared in December 2019 and is now a worldwide pandemic [1]. For healthcare workers (HCWs) performing aerosol-generating procedures (AGPs) on patients with infectious diseases such as COVID-19, airborne personal protective equipment (PPE) and precautions are required.

Chest compressions are one of the main components of cardiopulmonary resuscitation (CPR) and are an AGP [2]. Although the evidence is limited regarding whether chest compressions put HCWs at risk of transmission of acute respiratory infections, aerosols can be generated during CPR by intubation, suctioning of body fluids, and manual ventilation [3]. Therefore, a precautionary approach to airborne infections is appropriate during CPR. Chest compressions require intense and dynamic upper body movements; thus, it is possible that HCWs' masks could lose close contact with their face during chest compression, which could then create a gap in which air could flow.

The National Institute for Occupational Safety and Health (NIOSH)-certified N95 filtering facepiece respirators (N95 respirators) are recommended to protect against airborne droplets, based on the Centers for Disease Control and Prevention guidelines [4]. However, previous studies have shown that N95 respirators did not provide adequate protection during chest compressions due to inappropriate fitting [5,6]. According to the NIOSH regulations, powered air-purifying respirators (PAPRs) are specified for high-hazard procedures such as AGPs, although PAPRs have been mainly used for industrial purposes and are not certified as medical devices. PAPRs, which use a battery-powered fan to draw ambient air through a filter and direct the filtered air into the breathing zone, can offer high protective performance. A previous study reported that loose-fitting PAPRs provide sufficient respiratory protection and comfort during chest compressions [7]. However, no studies have investigated whether other types of PAPRs, such as tight-fitting PAPRs, provide and maintain a protective effect during chest compressions.

Here, we aimed to 1) investigate the protective effect of tight-fitting PAPRs during chest compressions and 2) to clarify the safe and suitable use of PAPRs in the care of patients with airborne infectious diseases.

Section snippets

Study design and setting

This was a simulation study conducted at a single center from February 2021 to March 2021. The study was performed in an isolated room located at the Nagoya University Hospital (Nagoya, Japan). The Institutional Review Board of the hospital approved the study and written informed consent was obtained from each participant.

Participant selection

The inclusion criteria were as follows: 1) HCWs who were employed at our institution; 2) HCWs who were 20 years of age or older; and 3) those certified for the delivery of

Characteristics of the study subjects

Fifty-four participants were included in this study. Table 1 shows the participant characteristics. Overall, the median age was 34 (IQR 27–41) years, 39% (n = 21) were female, and the median body mass index was 21.4 (IQR 20.0–24.1). Participants were employed as doctors (57%, n = 31), nurses (33%, n = 18), and others (9%, n = 5).

Outcomes

Primary and secondary outcomes are presented in Table 2. Overall, 78% (n = 42) of the participants failed (SWPF <500) at least one of the three sessions of chest

Discussion

PPE worn by HCWs is critical for reducing infection transmission in healthcare settings, especially during the COVID-19 pandemic. Airborne PPE and precautions are required when AGPs are being performed.

Previous simulation studies showed that the use of N95 respirators did not result in adequate protection due to inappropriate fit; the FF decreased to <100 in most participants during chest compression [5,6]. Another previous simulation study showed that a loose-fitting PAPR provides sufficient

Conclusions

Tight-fitting PAPRs did not provide adequate protection during chest compressions. The results of the present study indicate that the protective effect of tight-fitting PAPRs is affected by the dynamic movements of the body. Further studies must be conducted to revise the guidelines for the level of respiratory protection for HCWs during CPR in patients with airborne diseases. Further randomized trials are needed to determine the appropriate type or level of respiratory protective equipment

Funding sources/disclosures

This study was supported by research grants from Nakatani Foundation for advancement of measuring technologies in biomedical engineering [grant number; 2020Z047]. The funding source had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. The authors report no conflict of interest.

Credit author statement

Conception and design of study: YG, NJ, DK;

acquisition of data: YG, HH, HO, YS, MH, TY;

analysis and/or interpretation of data: YG, NJ, DK, TT, AN.

Drafting the manuscript: YG, NJ, DK;

revising the manuscript critically for important intellectual content: YG, NJ, HH, HO, YS, DK, TT, MH, TY, AN.

Approval of the version of the manuscript to be published: YG, NJ, HH, HO, YS, DK, TT, MH, TY, AN.

References (18)

There are more references available in the full text version of this article.
View full text
© 2021 Elsevier Inc. All rights reserved.