COVID-19 and Personal Protective Equipment

1. What is the position of the ASA on the use of Personal Protective Equipment, including an N95 mask?

• ASA, APSF, AAAA and AANA have released a joint statement on the use of Personal Protective Equipment. The ASA also supports anesthesia professionals purchasing and wearing alternate approved respirators, if they choose to do so. On April 19, the ASA issued an additional statement on “Facility Requirement for Personal Protective Equipment.” ASA recommendations on treating COVID-19 and suspected COVID-19 patients is available online. 

2. What PPE should I use for patients who have tested negative for COVID-19?

• Please review the ASA joint statement on PPE during the COVID-19 pandemic.

3. 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.

4. I am concerned that current PPE guidelines do not reflect the transmission risks from asymptomatic individuals. What PPE should we use?

• ASA, APSF, AAAA, and AANA have provided PPE recommendations highlighting the uncertainty of patients’ COVID-19 status and the need for practitioner safety, addressing contingencies that anesthesiologists face at their local facilities. The decision on whether a patient is suspected of COVID-19 infection should be made individually based on clinical, history and testing where possible. The suspicion of asymptomatic COVID-19 infection should be considered in areas with community spread. Ideally, anesthesiologists and other members of the healthcare team should have an adequate supply of N95 masks for caring of all patients whether symptomatic or not.
• We know that PPE is in short supply in many areas of the country. We further encourage physicians to discuss the availability of PPE and other resources for surgical care with your local leadership and to develop a plan to balance resource constraints with need to protect all providers. 
• Please review the Personal Protective Equipment FAQ section for additional details on reusing N95 masks. In general, The CDC and NIOSH have released guidance on reusing PPE. Anesthesiologists should also contact the manufacturer of devices and PPE to ensure that cleaning and reusing such devices and materials are safe and maintain their effectiveness. Please also see the APSF recommendations for processes to eliminate COVID-19 from N95 masks.

5. 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.

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

• The CDC and NIOSH have released guidance on optimizing the supply of PPE and additional information on reusing PPE. Anesthesiologists should also 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 inventor of the material used in the N95 mask, Dr. Peter Tsai, suggests that droplets and viable viruses will dry and no longer carry risk of transmission if the masks are not obviously soiled and are carefully stored in brown paper bags (so that air can circulate to them for drying) for at least 3 days. The CDC supports this approach if really necessary to allow re-use but suggests a five day period of drying. A practical application, if sufficient numbers of N95 masks are available, would be to issue 5 masks to everyone, and then have them rotate the use and storage of masks in a cycle. Information circulating through social media suggests that placing N95 masks in ovens at 70° C for 30 minutes will decontaminate N95 masks, also. The CDC explicitly does not support this approach to decontaminating N95 masks, suggesting that the dry heat may harm the protective integrity of the masks. The National Institutes of Health also released a study on the efficacy of decontamination methods.
• ASA has also learned of other ways practices are reusing masks. We recognize that personal protective equipment, including N95 masks, is in short supply and that anesthesiologists may need additional information on reusing or repurposing PPE. In one case, members of the anesthesia care team are planning to reuse disposable PAPR (Powered Air-Purifying Respirator) hoods after wiping them down as well as using available reusable military grade PAPR. The PAPR filter cartridges will also be reused with care to avoid contamination. Groups have also planned to create their own ‘N95’ utilizing an anesthesia circuit mask plus a Pall Ultipor® filter plus a strap to secure a makeshift solution. This may be helpful for short, but high-risk procedures. We also are aware of hospitals and facilities using ultraviolet germicidal irradiation (UVGI) as a practical method to decontaminate the N95 mask.
• 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.

7. Because of PPE shortages, anesthesiologists are turning to the Internet/social media for solutions. What are legitimate resources ASA can point to?

• At this time, ASA is not vetting or endorsing videos, products or other local solutions that individual physicians, hospitals or persons have created related to N95 or PPE. ASA offers links to websites for articles, training and information that have been published by specialty societies, peer-reviewed journals and other sources that have previously established their reliability.

8. 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.

9. 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.

10. 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. 

11. 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.

12. If operating room staff do not have N95s, what are people doing to protect them from aerosolization from RSI?

• We are concerned about any facility that does not have proper PPE for the intubation or extubation of COVID-19 and suspected COVID-19 patients. There is no safe substitute for wearing full, appropriate PPE for these aerosol generating procedures. Lower levels of PPE increase the risk of infection. If limited quantities of PPE are available, please see the CDC recommendations on extended use and limited reuse of PPE, including N95s.
  
  Using barrier methods may aid in reducing viral particle exposure in general, although there are no data on actual effectiveness. Additionally, the use of videolaryngoscopes may enable the person intubating to remain further away from the airway. Limiting the number of staff members present for intubations/extubations to reduce the risk of unnecessary exposure is recommended.

13. Under what circumstances would ASA feel comfortable recommending de-escalation of PPE requirements? 

• At this time, no regulatory body or national organization has recommended de-escalation of PPE requirements. PPE exists for the protection of staff caring for patients. The Occupational Safety and Health Administration (OSHA) states that employers “must provide a workplace free of known health and safety hazards.” ASA recommendations are based on review of the guidance provided by CDC, major medical organizations and current medical literature. These recommendations are dynamic and ASA is closely monitoring new guidelines or recommendations as they are developed.

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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.