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• W2015261300 abstract "The concurrent use of N95 filtering facepiece respirators with powered air-purifying respirators during aerosol-generating medical procedures in patients with severe respiratory pathogens has been promoted as offering additional protection against infectious agents. The purpose of this article is to examine the impact of this additional respiratory equipment upon protection and personal performance. The presumed additive protective effect of an N95 filtering facepiece respirator used concurrently with a powered air-purifying respirator has not been subjected to rigorous scientific investigation. The burden imposed by additional respiratory protective equipment should not be discounted, and the potentially minor contribution to protection may be offset by the negative impact on personal performance. Novel uses of protective equipment occasionally are spawned during crisis situations, but their generalized applicability to healthcare workers should ultimately be evidence-based. The concurrent use of N95 filtering facepiece respirators with powered air-purifying respirators during aerosol-generating medical procedures in patients with severe respiratory pathogens has been promoted as offering additional protection against infectious agents. The purpose of this article is to examine the impact of this additional respiratory equipment upon protection and personal performance. The presumed additive protective effect of an N95 filtering facepiece respirator used concurrently with a powered air-purifying respirator has not been subjected to rigorous scientific investigation. The burden imposed by additional respiratory protective equipment should not be discounted, and the potentially minor contribution to protection may be offset by the negative impact on personal performance. Novel uses of protective equipment occasionally are spawned during crisis situations, but their generalized applicability to healthcare workers should ultimately be evidence-based. The recent outbreak of severe acute respiratory syndrome (SARS) served to highlight the risk of disease transmission among health care workers (HCWs). The personal toll on HCWs has been distressing, as they have accounted for sizeable proportions of early cases of SARS and 20% of critically ill SARS cases.1Nicas M. Harrison R. Respiratory protection and severe acute respiratory syndrome.J Occup Environ Med. 2004; 6: 193-197Google Scholar, 2Fowler R.A. Guest C.B. Lapinsky S.E. Sibbald W. Louie M. Tang P. et al.Transmission of severe acute respiratory syndrome during intubation and mechanical ventilation.Resp Crit Care Med. 2004; 169: 1198-1202Crossref PubMed Google Scholar The concurrent threat of other emerging severe respiratory pathogens (eg, avian influenza, pandemic influenza, etc) has amplified the concerns of HCWs for adequate personal protective equipment (PPE). These respiratory viral pathogens are thought to be transmitted primarily by direct contact through exposure to large respiratory droplets (>5 μm in diameter) expelled during coughing and sneezing, or by contact with infected surfaces and fomites.3Seto W.H. Tsang D. Yung R.W.H. Ching T.Y. Ng T.K. Ho M. et al.Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS).Lancet. 2003; 361: 1519-1520Abstract Full Text Full Text PDF PubMed Scopus (702) Google Scholar, 4Peng P.W.H. Wong D.T. Bevan D. Gardam M. Infection control and anesthesia: lessons learned from the Toronto SARS outbreak.Can J Anesth. 2003; 50: 989-997Crossref PubMed Scopus (69) Google Scholar, 5Yassi A. Moore D. FitzGerald J.M. Bigelow P. Hon C.-Y. Bryce E. et al.Research gaps in protecting healthcare workers from SARS and other respiratory pathogens: an interdisciplinary, multi-stakeholder, evidence-based approach.J Occup Environ Med. 2005; 47: 41-50PubMed Google Scholar Airborne transmission of viral pathogens is also considered to be possible via evaporation of larger droplets that form droplet nuclei (<5 μm in diameter) or by viral attachment to dust particles, either of which allow for prolonged air suspension.6Conly J.M. Personal protective equipment for preventing respiratory infections: what have we really learned?.Can Med Assoc J. 2006; 175: 263-264Crossref Scopus (12) Google Scholar A recent investigation that obtained positive air samples in hospital SARS units in Toronto added plausibility to the theory of airborne transmission of SARS.7Booth T.F. Kournikakis B. Bastien N. Ho J. Kobasa D. Stadnyk L. et al.Detection of airborne severe acute respiratory syndrome (SARS) coronavirus and environmental contamination in SARS outbreak units.J Infect Dis. 2005; 191: 1472-1477Crossref PubMed Scopus (328) Google Scholar Medical procedures that result in aerosolization and subsequent airborne dissemination of respiratory pathogens (eg, endotracheal intubation, oral suctioning, etc) were identified as placing HCWs at increased risk for SARS infection.2Fowler R.A. Guest C.B. Lapinsky S.E. Sibbald W. Louie M. Tang P. et al.Transmission of severe acute respiratory syndrome during intubation and mechanical ventilation.Resp Crit Care Med. 2004; 169: 1198-1202Crossref PubMed Google Scholar, 6Conly J.M. Personal protective equipment for preventing respiratory infections: what have we really learned?.Can Med Assoc J. 2006; 175: 263-264Crossref Scopus (12) Google Scholar, 8Christian M.D. Loutfy M. McDonald L.C. Martinez K.F. Ofner M. Wong T. et al.Possible SARS coronavirus transmission during cardiopulmonary resuscitation.Emerg Infect Dis. 2004; 10: 287-293Crossref PubMed Scopus (214) Google Scholar, 9Gamage B. Moore D. Copes R. Yassi A. Bryce E. Protecting health care workers from SARS and other respiratory pathogens: a review of the infection control literature.Am J Infect Control. 2005; 33: 114-121Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar The finding that HCWs were infected with SARS during some of these aerosol-generating procedures, despite the use of accepted universal precautions (ie, gowns, caps, gloves, eye protection [eg, face shields, goggles], N95 [or equivalent] filtering facepiece respirators [N95FFR]), resulted in medical specialists,4Peng P.W.H. Wong D.T. Bevan D. Gardam M. Infection control and anesthesia: lessons learned from the Toronto SARS outbreak.Can J Anesth. 2003; 50: 989-997Crossref PubMed Scopus (69) Google Scholar, 10Kamming D. Gardam M. Chung F. Anesthesia and SARS.Brit J Anaesth. 2003; 90: 715-718Crossref PubMed Scopus (101) Google Scholar, 11Oh V.M.S. Lim T.K. Singapore's experience of SARS.Clin Med. 2003; 3: 448-451Crossref PubMed Scopus (17) Google Scholar health care agencies,12Ontario Ministry of Health and Long-Term Care Directive HR03-12. Directive to all Ontario acute care facilities for high-risk respiratory procedures. Available at: https://sars.medtau.org/revisedhighrisk.pdf. Accessed October 12, 2006.Google Scholar, 13Ministry of Health Singapore. Manual for SARS control in hospitals, April 24, 2003. Available at: http://www.moh.gov.sg/corp/sars/oldpdf/SARS_MOH_manual_2610403.pdf. Accessed February 7, 2007.Google Scholar professional societies,14Lapinsky S. Hawryluck L. Wax R. SARS in the crucially ill patient.Critical Care Rounds. 2003; 4: 1-6Google Scholar and medical institutions15Wong D.T. Protection protocol in intubation of suspected SARS patients.Can J Anesth. 2003; 50: 747-748Crossref PubMed Scopus (9) Google Scholar promoting the use of powered air-purifying respirators (PAPRs) for HCWs involved in these procedures. Ancillary recommendations included the concurrent use of N95FFR (or equivalent respirators) and goggles with PAPRs,4Peng P.W.H. Wong D.T. Bevan D. Gardam M. Infection control and anesthesia: lessons learned from the Toronto SARS outbreak.Can J Anesth. 2003; 50: 989-997Crossref PubMed Scopus (69) Google Scholar, 13Ministry of Health Singapore. Manual for SARS control in hospitals, April 24, 2003. Available at: http://www.moh.gov.sg/corp/sars/oldpdf/SARS_MOH_manual_2610403.pdf. Accessed February 7, 2007.Google Scholar, 15Wong D.T. Protection protocol in intubation of suspected SARS patients.Can J Anesth. 2003; 50: 747-748Crossref PubMed Scopus (9) Google Scholar, 16Khoo K.-L. Leng P.-H. Ibrahim I.B. Lim T.K. The changing face of healthcare worker perceptions on powered air-purifying respirators during the SARS outbreak.Respirology. 2005; 10: 107-110Crossref PubMed Scopus (59) Google Scholar, 17Ontario Ministry of Health and Long-Term Care, Directive HR03-06R, Directive to all Ontario acute care hospitals for high-risk procedures involving SARS patients critical care areas, May 13, 2003. Available at: http://www.health.gov.on.ca/english/public/public_mn.html. Accessed October 12, 2006.Google Scholar based upon the assumption that this combination of PPE would act in an additive fashion to provide maximal protection10Kamming D. Gardam M. Chung F. Anesthesia and SARS.Brit J Anaesth. 2003; 90: 715-718Crossref PubMed Scopus (101) Google Scholar (Fig 1). However, the respiratory protection afforded by the concurrent use of PAPRs with N95FFR (N95FFR/PAPR), as well as any recommendations to the contrary, have not been subjected to scientific scrutiny, as is true for many recommendations regarding the prevention of transmission of SARS-related coronavirus in health care settings.18Nicolle L. SARS safety and science.Can J Anesth. 2003; 50: 983-988Crossref PubMed Scopus (39) Google Scholar Improper use of PPE can negatively impact the wearer in such areas as personal performance, safety, physical and emotional comfort, communication, and hearing such that it is incumbent upon PPE users and hospital respiratory protection program managers to determine the relative merits of employing additional PPE in novel ways, particularly if the novel aspects of use have not been thoroughly evaluated for effectiveness. Any additional burden imposed on the user must also be carefully considered. This article examines the use of N95FFR/PAPRs in the setting of respiratory pathogens during aerosol-generating medical procedures to encourage a more thorough evaluation of this regimen by professional societies, regulatory bodies, and users of this combination of PPE. The most common respirators utilized by HCWs, N95 filtering facepiece respirators (N95FFR) (Fig 2) are disposable filtering facepiece PPE devices that are worn on the face, cover at least the nose and mouth, and are used to reduce the wearer's risk of inhaling hazardous airborne particles (including dust particles and infectious agents) or aerosols.19Yassi A, Bryce E. Protecting the faces of health care workers. Knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. Occupational Health and Safety Agency for Healthcare in British Columbia, April 30, 2004. Available at: http://www.ohsah.bc.ca/index.php?section_id=441&section_copy_id=396. Accessed October 14, 2006.Google Scholar To be approved by the National Institute for Occupational Safety and Health, the U.S. agency responsible for the certification of respiratory protective devices, filtering facepiece respirators must pass a number of tests. Letter designations (eg, N, R, P) reflect the respirator's resistance to oil particles (N = not resistant to oil particles; R = somewhat resistant to oil particles; P = oil proof).20Tobis B.J. Respiratory protection for severe acute respiratory syndrome (SARS).Disaster Mgmt & Response. 2003; 1: 91-92Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Numerical designations (95, 99, and 100 [99.97 actual]) indicate the minimum filtration efficiency of the respirator filter (particle penetration of ≤5%, ≤1%, and ≤0.03%, respectively) to a challenge aerosol consisting of particles in the most penetrating particle size range (approximately 0.3 μm test particles) delivered at a flow rate of 85 L/min.19Yassi A, Bryce E. Protecting the faces of health care workers. Knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. Occupational Health and Safety Agency for Healthcare in British Columbia, April 30, 2004. Available at: http://www.ohsah.bc.ca/index.php?section_id=441&section_copy_id=396. Accessed October 14, 2006.Google Scholar, 2142 Code of Federal Regulations, Part 84. Respiratory protective devices, June 2, 1995. Available at: http://www.cdc.gov/niosh/pt84abs2.html. Accessed October 12, 2006.Google Scholar Therefore, an N95FFR has a minimum 95% filtration efficiency (or a maximum of 5% penetration rate through the respirator filter using a small test aerosol), and has an assigned protection factor (APF) (the minimum anticipated protection provided by a properly functioning respirator or class of respirators to a given percentage of properly fitted and tested users, when used in a complete respiratory program) of 10, indicating that properly fitted and trained users could expect to inhale no more than one-tenth of the airborne contaminant present.22U.S. Department of Labor, Occupational Safety & Health Administration. Assigned Protection Factors; Final Rule—71:50121-50192. Available at: http://www.osha.gov/SLTC/etools/respiratory/haz_expose/apf/apf.html. Accessed April 20, 2007.Google Scholar, 23U.S. Department of Labor, Occupational Health and Safety Administration, Standard 29 CFR 1910.134, Respiratory Protection, August 23, 2006. Available at: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=18846. Accessed October 21, 2006.Google Scholar APFs are based on laboratory and workplace studies that measure the ratio of the ambient contaminant concentration to the contaminant concentration inside a respirator and are used for selecting what type of respirator to employ in a given situation.24Nelson T.J. Jayjock M.A. Colton C.E. How protective are respirator assigned protection factors: an uncertainty analysis.Am Indust Hyg Assoc J. 2000; 61: 388-393Google Scholar Use of a respirator with an APF greater than the calculated hazard risk (ie, ambient concentration of a contaminant ÷ established permissible exposure limit) generally assumes that the exposure inside the respirator will be less than the exposure limit.24Nelson T.J. Jayjock M.A. Colton C.E. How protective are respirator assigned protection factors: an uncertainty analysis.Am Indust Hyg Assoc J. 2000; 61: 388-393Google Scholar However, it is important to recognize that, as opposed to particulates and chemicals, governmental regulatory agencies have not established safe exposure levels for biological aerosols; thus, there is no assurance that any respirator will completely eliminate the inhalation of pathogenic microorganisms. Nonetheless, it is assumed that the higher the APF, the more protection afforded the wearer.19Yassi A, Bryce E. Protecting the faces of health care workers. Knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. Occupational Health and Safety Agency for Healthcare in British Columbia, April 30, 2004. Available at: http://www.ohsah.bc.ca/index.php?section_id=441&section_copy_id=396. Accessed October 14, 2006.Google Scholar PAPRs (Fig 3) are respiratory protective devices in which a belt-mounted, battery-powered blower pulls ambient air through attached air-purifying filters (housed in cassettes or canisters) through a hose and into a facepiece. The facepiece can be either tight-fitting (ie, half facepiece or full facepiece) or loose-fitting (ie, shroud, helmet).19Yassi A, Bryce E. Protecting the faces of health care workers. Knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. Occupational Health and Safety Agency for Healthcare in British Columbia, April 30, 2004. Available at: http://www.ohsah.bc.ca/index.php?section_id=441&section_copy_id=396. Accessed October 14, 2006.Google Scholar The continuous airflow (170 L/min) through loose-fitting hoods or shrouds limits entrainment of contaminated air.25Mount Sinai Hospital Critical Care Unit, SARS Resources. Available at: http://www.sars.medtau.org. Accessed October 3, 2005.Google Scholar Additionally, PAPRs possess several other features that make them attractive to HCWs and hospital administrators (Table 1). In the health care setting, the loose-fitting facepiece/visor PAPR is the predominant model,19Yassi A, Bryce E. Protecting the faces of health care workers. Knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. Occupational Health and Safety Agency for Healthcare in British Columbia, April 30, 2004. Available at: http://www.ohsah.bc.ca/index.php?section_id=441&section_copy_id=396. Accessed October 14, 2006.Google Scholar although shrouded PAPRs are increasingly advocated in the context of health care chemical, biological, radiation, and nuclear response because they offer greater dermal protection to the head/neck regions than helmeted PAPR.26Zamora J.E. Murdoch J. Simchison B. Day A.G. Contamination: a comparison of 2 personal protective systems.Can Med Assoc J. 2006; 175: 249-254Crossref PubMed Scopus (84) Google Scholar Loose-fitting PAPRs (eg, hoods, helmets) have an APF of 25.22U.S. Department of Labor, Occupational Safety & Health Administration. Assigned Protection Factors; Final Rule—71:50121-50192. Available at: http://www.osha.gov/SLTC/etools/respiratory/haz_expose/apf/apf.html. Accessed April 20, 2007.Google ScholarTable 1Beneficial aspects of loose-fitting powered air-purifying respirators used by health care workersNo requirement for annual fit testingMore comfortable than tight-fitting air-purifying respiratorsLess respiratory effort required than negative pressure respiratorsMore mobility than air-supplied respiratorsLess weight than self-contained breathing apparatiCooling effect of air currentsCan be worn with eyewear or facial hairN95FFRs can be worn concomitantly (not currently NIOSH-approved)Can be worn for up to 8 hours on one battery charge Open table in a new tab The rationale for N95FFR/PAPR use has been based on the desire to maximize respiratory protection via a presumed additive protective effect of dual respiratory PPE use.8Christian M.D. Loutfy M. McDonald L.C. Martinez K.F. Ofner M. Wong T. et al.Possible SARS coronavirus transmission during cardiopulmonary resuscitation.Emerg Infect Dis. 2004; 10: 287-293Crossref PubMed Scopus (214) Google Scholar, 10Kamming D. Gardam M. Chung F. Anesthesia and SARS.Brit J Anaesth. 2003; 90: 715-718Crossref PubMed Scopus (101) Google Scholar Proponents cited years of personal experience with PAPRs during bronchoscopy on patients with suspected pulmonary infections such as tuberculosis without subsequent transmission of infection to HCW as supportive of this concept, but it is unclear whether PAPRs alone or N95FFR/PAPRs were employed during these procedures.4Peng P.W.H. Wong D.T. Bevan D. Gardam M. Infection control and anesthesia: lessons learned from the Toronto SARS outbreak.Can J Anesth. 2003; 50: 989-997Crossref PubMed Scopus (69) Google Scholar, 10Kamming D. Gardam M. Chung F. Anesthesia and SARS.Brit J Anaesth. 2003; 90: 715-718Crossref PubMed Scopus (101) Google Scholar Additional rationale supporting N95FFR/PAPR use included backup protection in the event of battery failure14Lapinsky S. Hawryluck L. Wax R. SARS in the crucially ill patient.Critical Care Rounds. 2003; 4: 1-6Google Scholar or from over-breathing (momentary episodes of negative pressure in a PAPR brought about when the user's maximum peak inspiratory airflow exceeds the PAPR airflow delivery)27Janssen L.L. Anderson N.J. Cassidy P.E. Weber R.A. Nelson T.J. Interpretation of inhalation airflow measurements for respirator design and testing.J Int Soc Resp Protection. 2005; (22:122:141)Google Scholar resulting in loss of the positive pressure effect of the PAPR.28Wax R, Brunet F, Peerbaye Y, et al. Draft report—working group on adjunctive protective equipment for high-risk procedures in SARS patients. Available at: http://www.SARS.medtau.org/adjunctivereport.doc. Accessed October 3, 2005.Google Scholar Central to the discussion of N95FFR/PAPR use is the issue of whether the presumed (but unproven) benefit of this combination outweighs the increased burden imposed on the user by the additional PPE equipment employed and how this might affect HCW performance. For instructional purposes, let us examine endotracheal intubation in a patient, a high-risk procedure for aerosolization and disease transmission, because mechanical irritation of the airway by the equipment employed (eg, suction catheter, laryngoscope, endotracheal tube, etc) can induce forceful coughing and extend the duration of coughing,29Gal T.J. Effects of endotracheal intubation on normal cough performances.Anesthesiology. 1980; 52: 324-329Crossref PubMed Scopus (37) Google Scholar and the operator's face is in close proximity to the patient's mouth during airway procedures.30Nicas M. Assessing the relative importance of the components of an occupational tuberculosis control program.J Occup Environ Med. 1998; 40: 648-654Crossref PubMed Scopus (11) Google Scholar To ascertain the potential exposure to HCW, the pathogen emission rate is determined from the product of the number of coughs per hour, respirable volume per cough, and pathogen concentration per milliliter of respiratory fluid.31Centers for Disease Control and Prevention. Workshop on respiratory protection for airborne infectious agents. November 30–December 1, 2004, Atlanta, Georgia. Available at: http://frwebgate1.access.gpo.gov/cgi-bin/waisgate.cgi?WAISdocID=819418513377+0+0+0&WAI Saction=retrieve. Accessed October 22, 2006.Google Scholar It would also be informative to have data regarding the number of pathogen particles needed to infect and the number carried on any individual respiratory droplet; however, these data are currently unknown, though it is recognized that some serious respiratory pathogens (eg, tuberculosis, influenza) require as few as 1-3 organisms to cause infection.32Musher D.M. How contagious are common respiratory tract infections?.N Engl J Med. 2003; 348: 1256-1266Crossref PubMed Scopus (236) Google Scholar Distance from the patient is also a consideration inasmuch as the concentration of airborne particles in still air decreases in proportion to 1/d3 (where d is the distance from the source of the aerosol), so that someone who is 2 meters away from a coughing patient has one-eighth the exposure concentration of someone who is 1 meter away.33Thiessen R.J. Filtration of respired gases: theoretical aspects.Resp Care Clinics. 2006; 12: 183-201PubMed Google Scholar Thus, in this scenario, potential exposures are probably influenced more by pathogen particles generated acutely during the procedure than those extant in the room that have been diluted by the ventilation system's hourly room air exchanges. The APF of 25 assigned by the Occupational Safety and Health Administration to a loose-fitting PAPR indicates a potential 4% penetration into the unit's breathing zone,22U.S. Department of Labor, Occupational Safety & Health Administration. Assigned Protection Factors; Final Rule—71:50121-50192. Available at: http://www.osha.gov/SLTC/etools/respiratory/haz_expose/apf/apf.html. Accessed April 20, 2007.Google Scholar a not-insignificant proportion when dealing with infectious agents that may require relatively few particles to infect. Although the use of a concurrent N95FFR (APF 10) could potentially decrease the in-PAPR exposure by 90% (depending on such factors as the N95FFR model employed, respirator condition, fit-testing, etc), no studies have yet evaluated the efficacy of an N95FFR/PAPR combination; consequently, no firm conclusions can be drawn. Alternatively, recent human studies on loose-fitting PAPR27Janssen L.L. Anderson N.J. Cassidy P.E. Weber R.A. Nelson T.J. Interpretation of inhalation airflow measurements for respirator design and testing.J Int Soc Resp Protection. 2005; (22:122:141)Google Scholar, 34Cohen H.J. Hecker L.H. Mattheis D.K. Johnson J.S. Biermann A.H. Foote K.L. Simulated workplace protection factor study of powered air-purifying and supplied air respirators.Am Ind Hyg Assoc J. 2001; 62: 595-604Google Scholar have concluded that they afford actual workplace protection many times the APF, thereby offering even greater protection than officially assigned. Published reports from the health care environment suggest that PAPRs alone offer sufficiently high levels of respiratory protection during aerosolizing medical procedures. Caputo et al35Caputo K.M. Byrick R. Chapman M.G. Orser B.J. Orser B.A. Intubation of SARS patients: infection and perspectives of healthcare workers.Can J Anesth. 2006; 53: 122-129Crossref PubMed Scopus (88) Google Scholar reported that no SARS developed in HCW who used a Stryker T4 surgical helmet (filters air through the hood material itself; airborne reduction factor of 3.1 for particles >0.5 μm in diameter8Christian M.D. Loutfy M. McDonald L.C. Martinez K.F. Ofner M. Wong T. et al.Possible SARS coronavirus transmission during cardiopulmonary resuscitation.Emerg Infect Dis. 2004; 10: 287-293Crossref PubMed Scopus (214) Google Scholar) with tandem N95FFR respirator (APF 10) during intubations on SARS victims, despite the fact that this combination offers significantly less respiratory protection than a loose-fitting PAPR (APF 25). Furthermore, the conditional risk of a respiratory-transmitted disease such as tuberculosis (one tuberculosis bacterium can cause seroconversion32Musher D.M. How contagious are common respiratory tract infections?.N Engl J Med. 2003; 348: 1256-1266Crossref PubMed Scopus (236) Google Scholar) in high-risk situations such as aerosol-inducing procedures (ie, bronchoscopy) has been estimated to be as low as 0.3 cases per 1000 procedures when using a PAPR.30Nicas M. Assessing the relative importance of the components of an occupational tuberculosis control program.J Occup Environ Med. 1998; 40: 648-654Crossref PubMed Scopus (11) Google Scholar Use of a PAPR during bronchoscopy, in patients with tuberculosis, results in a 238-fold risk reduction of seroconversion.36Barnhart S. Sheppard L. Beaudet N. Stover B. Balmes J. Tuberculosis in health care settings and the estimated benefits of engineering controls and respiratory protection.J Occup Environ Med. 1997; 39: 849-854Crossref PubMed Scopus (41) Google Scholar Perhaps most importantly, no reports of well-documented, active tuberculosis or other serious infections to HCWs wearing PAPRs have been reported in association with bronchoscopy (>500,000 bronchoscopies performed annually in the U.S.), an aerosol-generating procedure for which PAPR use is recommended.37Culver D.A. Gordon S.M. Mehta A.C. Infection control in the bronchoscopy suite.Resp Crit Care Med. 2003; 167: 1050-1056Crossref PubMed Scopus (65) Google Scholar All of this suggests that properly used and maintained loose-fitting PAPRs offer a high degree of protection from respiratory pathogens. Hospital engineering controls (eg, negative pressure rooms, room ventilation systems with high efficiency particulate filters, ultraviolet radiation, etc8Christian M.D. Loutfy M. McDonald L.C. Martinez K.F. Ofner M. Wong T. et al.Possible SARS coronavirus transmission during cardiopulmonary resuscitation.Emerg Infect Dis. 2004; 10: 287-293Crossref PubMed Scopus (214) Google Scholar) and the use of medications to suppress coughing and salivation during airway procedures4Peng P.W.H. Wong D.T. Bevan D. Gardam M. Infection control and anesthesia: lessons learned from the Toronto SARS outbreak.Can J Anesth. 2003; 50: 989-997Crossref PubMed Scopus (69) Google Scholar, 10Kamming D. Gardam M. Chung F. Anesthesia and SARS.Brit J Anaesth. 2003; 90: 715-718Crossref PubMed Scopus (101) Google Scholar, 35Caputo K.M. Byrick R. Chapman M.G. Orser B.J. Orser B.A. Intubation of SARS patients: infection and perspectives of healthcare workers.Can J Anesth. 2006; 53: 122-129Crossref PubMed Scopus (88) Google Scholar, 38Mehta A.C. Prakash U.B.S. Garland R. Haponik E. Moses L. Schaffner W. et al.American College of Chest Physicians and American Association for Bronchology consensus statement. Prevention of flexible bronchoscopy-associated infection.Chest. 2005; 128: 1742-1755Crossref PubMed Scopus (118) Google Scholar, 39Abrahamson S.D. Canzian S. Brunet F. Using simulation for training and to change protocol during the outbreak of severe acute respiratory syndrome.Crit Care. 2005; 10: 1-6Google Scholar further limit the airborne spread of respiratory pathogens and would additionally decrease the PAPR wearer's potential inhalational exposure. With regard to the use of N95FFR as a backup in the event of battery failure, PAPR low battery-life alarms (visual and/or audible) allow sufficient time for room egress. Overbreathing,27Janssen L.L. Anderson N.J. Cassidy P.E. Weber R.A. Nelson T.J. Interpretation of inhalation airflow measurements for respirator design and testing.J Int Soc Resp Protection. 2005; (22:122:141)Google Scholar as occurs with strenuous physical activity, and momentarily during nonrespiratory air exchanges (eg, yawning, sighing, preparatory to coughing or sneezing, etc), can result in loss of positive pressure effects within the PAPR and subsequent entrainment of outside air. However, even when such activities result in peak inspiratory flow rates that exceed the PAPR flow rate, aerosol penetration into the PAPR has been shown to remain below 0.1% of the ambient concentration.40Bostock G. An investigation into the performance of positive pressure powered dust hoods and blouses at low flow rates.Ann Occup Hyg. 1985; 29: 415-" @default.
• W2015261300 created "2016-06-24" @default.
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• W2015261300 date "2008-03-01" @default.
• W2015261300 modified "2023-10-10" @default.
• W2015261300 title "Evaluation of the rationale for concurrent use of N95 filtering facepiece respirators with loose-fitting powered air-purifying respirators during aerosol-generating medical procedures" @default.
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