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Classification of aerosol-generating procedures: a rapid systematic review
  1. Tanya Jackson1,
  2. Danika Deibert1,
  3. Graeme Wyatt1,
  4. Quentin Durand-Moreau1,
  5. Anil Adisesh2,
  6. Kamlesh Khunti3,
  7. Sachin Khunti4,
  8. Simon Smith5,
  9. Xin Hui S Chan6,
  10. Lawrence Ross7,
  11. Nia Roberts8,
  12. Elaine Toomey9,
  13. Trisha Greenhalgh10,
  14. Isheeta Arora11,
  15. Susannah M Black11,
  16. Jonathan Drake11,
  17. Nandana Syam11,
  18. Robert Temple11 and
  19. Sebastian Straube1
  1. 1Division of Preventive Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
  2. 2Division of Occupational Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3Diabetes Research Centre, University of Leicester, Leicester, UK
  4. 4School of Medicine and Dentistry, Barts and the London School of Medicine and Dentistry, London, UK
  5. 5Canadian Standards Biological Aerosols Group, Canadian Standards Association, Toronto, Ontario, Canada
  6. 6Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
  7. 7Division of Infectious Diseases, Children’s Hospital of Los Angeles, Los Angeles, California, USA
  8. 8Bodleian Health Care Libraries, University of Oxford, Oxford, Oxfordshire, UK
  9. 9School of Allied Health, University of Limerick, Limerick, Ireland
  10. 10Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
  11. 11Medical Sciences Division, University of Oxford, Oxford, Oxfordshire, UK
  1. Correspondence to Professor Sebastian Straube; straube{at}ualberta.ca; Professor Trisha Greenhalgh; trish.greenhalgh{at}phc.ox.ac.uk

Abstract

In the context of covid-19, aerosol generating procedures have been highlighted as requiring a higher grade of personal protective equipment. We investigated how official guidance documents and academic publications have classified procedures in terms of whether or not they are aerosol-generating. We performed a rapid systematic review using preferred reporting items for systematic reviews and meta-analyses standards. Guidelines, policy documents and academic papers published in english or french offering guidance on aerosol-generating procedures were eligible. We systematically searched two medical databases (medline, cochrane central) and one public search engine (google) in march and april 2020. Data on how each procedure was classified by each source were extracted. We determined the level of agreement across different guidelines for each procedure group, in terms of its classification as aerosol generating, possibly aerosol-generating, or nonaerosol-generating. 128 documents met our inclusion criteria; they contained 1248 mentions of procedures that we categorised into 39 procedure groups. Procedures classified as aerosol-generating or possibly aerosol-generating by ≥90% of documents included autopsy, surgery/postmortem procedures with high-speed devices, intubation and extubation procedures, bronchoscopy, sputum induction, manual ventilation, airway suctioning, cardiopulmonary resuscitation, tracheostomy and tracheostomy procedures, non-invasive ventilation, high-flow oxygen therapy, breaking closed ventilation systems, nebulised or aerosol therapy, and high frequency oscillatory ventilation. Disagreements existed between sources on some procedure groups, including oral and dental procedures, upper gastrointestinal endoscopy, thoracic surgery and procedures, and nasopharyngeal and oropharyngeal swabbing. There is sufficient evidence of agreement across different international guidelines to classify certain procedure groups as aerosol generating. However, some clinically relevant procedures received surprisingly little mention in our source documents. To reduce dissent on the remainder, we recommend that (a) clinicians define procedures more clearly and specifically, breaking them down into their constituent components where possible; (b) researchers undertake further studies of aerosolisation during these procedures; and (c) guideline-making and policy-making bodies address a wider range of procedures.

  • infection control
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This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Footnotes

  • Contributors TJ contributed to searching, data extraction and data management, performed calculations, wrote manuscript text and managed references. DD contributed to searching and data extraction, classified procedures, performed calculations and wrote manuscript text. GW contributed to searching, data extraction and data management, wrote manuscript text and managed references. QD-M contributed to searching and data extraction. AA adjudicated differences in data extraction and classified procedures. KK, SK and SSm wrote manuscript text and contributed references. XHSC and LR classified procedures. NR contributed to searching. ET contributed to searching and data extraction. TG performed calculations and wrote manuscript text. IA, SMB, JD, NS and RT verified the data extraction. SSt conceived and directed the systematic review, extracted data, classified procedures and wrote manuscript text. All authors reviewed the manuscript and approved the final version before submission.

  • Funding Research support to Professor Straube at the University of Alberta was provided by a grant from the Workers’ Compensation Board of Alberta, ‘Program of Research and Training in Occupational Medicine’, which was used to employ Dr Jackson, Ms Deibert and Mr Wyatt for work on this project as well as to pay for the publication fee for this article. Professor Greenhalgh’s work is supported by UK National Institute for Health Research (BRC-1215-20008), UK Research and Innovation (COVID-19 Emergency Fund) and Wellcome Trust (WT104830MA). Professor Khunti is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands (ARC EM) and the NIHR Leicester Biomedical Research Centre (BRC). The views expressed are those of the authors and not necessarily those of any funders.

  • Disclaimer SSt is the manuscript’s guarantor and affirms that the manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Competing interests QD-M reports grants from the Workers’ Compensation Board of Alberta, during the conduct of the study. SSm reports other from 3M Canada Company, outside the submitted work. In addition, SSm has a patent P. Legare, G.E. Dwyer, A. Murphy, S.J. Smith ‘Air filtration device’ US Patent 9.744.493 and European Patent 2274067 (2008). issued, and a patent R.A. Abdulqader, S.C. Dodds, A.M. Gilman, A.D. Groth, C.P. Henderson, D.M. Maanum, L.V. Palaikis, N.A. Rakow, S.J. Smith, E. Evgeny, ‘Filtering face-piece respirator including functional material and method of forming same’ World Patent 201766284 (2015). issued. SSt reports grants from the Workers’ Compensation Board of Alberta during the conduct of the study; personal fees from the Workers’ Compensation Board of Alberta, personal fees from WorkSafeBC and personal fees from the Canadian Board of Occupational Medicine, outside the submitted work.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Much of the data is uploaded as a supplement. Those wishing additional raw data may contact Professor Straube.