COVID-19 and Personal Protective Equipment

1. Do we need N95s and full PPE working at the airway for all patients, even if we don't know their COVID-19 status?

• ASA, APSF, AAAA, and AANA have provided PPE recommendations addressing contingencies that anesthesiologists face at their local facilities. Due to close patient contact and the need for airway instrumentation, anesthesia professionals are at increased risk of exposure and infection for all diagnostic, therapeutic, and surgical procedures. Also, identification of who is COVID positive or negative with certainty may not be possible in the setting of clinical care, especially if there is community transmission. Therefore, ASA recommends as optimal practice that all anesthesia professionals should utilize full PPE appropriate for aerosol-generating procedures for all patients when working near the airway.
• Ideally, anesthesia professionals should use properly fitted N95 masks or powered air purifying respirators (PAPRs). If a facility has existing or projected shortages of N95 masks or PAPRs, however, temporary mitigation plans based on current CDC recommendations should be enacted. CDC offers guidance on conserving N95 respirators within the broader context of engineering and administrative control strategies to decrease personnel risk, in “Strategies for Optimizing the Supply of N95 Respirators.” In addition, CDC offers guidance to extend use/reuse of N95 respirators as a strategy to conserve supply in “Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings” and in implementing filter facepiece respirator reuse. The National Institutes of Health also released a study on the efficacy of decontamination methods. We encourage physicians to discuss the availability of PPE and other resources with your local leadership and to develop a plan to balance resource constraints with need to protect all providers. 

2. Regarding gowns and coveralls, is there any additional need for neck protection during airway manipulation of patients with known or suspected COVID-19 infection? Do we need a hood with neck cover for potential splashes of droplets during intubation or extubation?

• We recommend that you review guidance materials found on the CDC website . We recognize that head and neck coverings are not included in World Health Organization, CDC, or Canadian guidelines. However, head and neck protection helps to decrease the droplet contamination shown to occur in this area during simulated airway management. While the wrists are easily decontaminated by hand-sanitizing during and after the doffing procedure, the head and neck areas are often not. We encourage you to have conversations with infectious disease consultants, infection control staff and supply chain managers who can inform your judgment concerning the best of alternative choices to protect all your patients and staff.
• We recognize the risk that airway management has when a patient coughs during intubation or extubation, leading to contaminated mist and droplet formation. All authorities recommend that you do not touch your hands to your face. A face shield will protect your eyes and also the N95 mask from surface contamination. Some anesthesiologists are using a surgical mask over the N95 mask. We encourage you to have conversations with infectious disease consultants, infection control staff and supply chain managers who can inform your judgment concerning the best of alternative choices to protect all your patients and staff.

3. Can I reuse my N95 mask and other Personal Protective Equipment?

• Anesthesiologists should contact the manufacturer of devices and PPE to ensure that cleaning and reusing such devices and materials are safe and maintain their effectiveness.
• Please see the APSF recommendations for processes to eliminate coronavirus from N95 masks. The National Institutes of Health also released a study on the efficacy of decontamination methods.
• We recommend members conduct literature reviews, review resources on the CDC and NIOSH websites, contact the manufacturers and assess the risks and benefits associated with such actions.

4. For what procedures does ASA recommend the use of N95 masks?

• ASA recommends as optimal practice that all anesthesia professionals should utilize PPE appropriate for aerosol-generating procedures for all patients, during all diagnostic, therapeutic, and surgical procedures, when working near the airway. More complete guidance can be found in the ASA-APSF-AAAA-AANA joint statement. ASA recommendations on treating COVID-19 and PUIs include the use of PPE for aerosol-generating procedures.

5. Does ASA have a list of aerosolizing procedures in the operating room so that we can identify which procedures require PPE?

• According to the CDC there is neither expert consensus nor sufficient supporting data to create a definitive and comprehensive list of aerosol generating procedures (AGPs) for healthcare settings. Commonly performed anesthesia and critical care-related medical procedures  that are often considered AGPs, or that create uncontrolled respiratory secretions, include tracheal intubation and extubation, manual ventilation, non-invasive ventilation (e.g., BiPAP, CPAP), bronchoscopy, open suctioning of airways, sputum induction, and cardiopulmonary resuscitation. In addition , surgical societies, including the American College of Surgeons, cite procedures that are potentially aerosol-generating, including upper airway and skull base procedures, upper and lower GI endoscopies and laparoscopies. It is uncertain whether aerosols generated from some procedures may be infectious, such as nebulizer administration and high flow O₂ delivery.

6. What PPE should we use LMA and MAC in COVID-19 negative patients?

• ASA recommends using PPE in accordance with CDC guidance. Aerosolizing procedures should continue to use aerosolizing precautions (N95 respirator or equivalent, face shield, gown, and gloves). Further guidance on PPE is available on the ASA COVID-19 website. 

7. What types of masks should we use if N95s are not available?

• We support anesthesia professionals purchasing and wearing alternate approved respirators, if they choose to do so. The Joint Commission (PDF) also supports “allowing staff to bring their own standard face masks or respirators to wear at work.” There are no regulatory prohibitions that forbid health care professionals from wearing PPE when not required to. It is inappropriate for facilities to prohibit their employees from purchasing and wearing approved PPE.
• Please review the CDC website for appropriate masks to use. We recommend industrial masks that offer equal to or greater protection than N95 (e.g. N100). Some facilities have considered the use of a tight mask that can be constructed with available anesthesia supplies (disposable anesthesia mask, straps, and HEPA filter) or other full-face masks with straps and HEPA filter.
• We do not recommend hand sewn or other fabric masks that have not undergone careful testing because of concerns about fit and filtration capability.

Additional Information

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Disclaimer

Viewers of this material should review these FAQs with appropriate medical and legal counsel and make their own determinations as to relevance to their particular practice setting and compliance with state and federal laws and regulations. The ASA has used its best efforts to provide accurate information. However, this material is provided only for informational purposes and does not constitute medical or legal advice. This response also should not be construed as representing ASA policy (unless otherwise stated), making clinical recommendations, dictating payment policy, or substituting for the judgment of a physician and consultation with independent legal counsel.