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• W3204167863 abstract "FOR RELATED ARTICLE, SEE PAGES 1377 and 1388One of the silver linings of the COVID-19 pandemic has been the explosion of research on respiratory virus transmission mechanisms. The insights garnered from these studies have overturned deeply entrenched assumptions that have governed infection control practices for decades. FOR RELATED ARTICLE, SEE PAGES 1377 and 1388 Both the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have traditionally divided contagious respiratory pathogens into two transmission categories: droplet and airborne. Droplet pathogens are said to spread via large respiratory particles that rapidly fall to the ground within a few feet of the source individual. Surgical masks are recommended for providers seeing patients on droplet precautions. Most respiratory viruses, including influenza, and for much of the past year, SARS-CoV-2, have been classified as pathogens that spread via droplets. Airborne infections, by contrast, are said to spread via aerosols. These are smaller and lighter respiratory particles that can remain suspended in the air for long periods, penetrate the gaps between surgical masks and wearers’ faces, and spread throughout a room and beyond. N95 respirators or their equivalents are therefore advised for providers seeing patients on airborne precautions. Examples include measles and TB. There is an important exception to CDC’s and WHO’s general guidance to use surgical masks when seeing patients on droplet precautions. N95 respirators or their equivalents are recommended for patients with influenza or SARS-CoV-2 undergoing so-called “aerosol-generating procedures,” such as intubation, noninvasive positive-pressure ventilation, and tracheotomy, because these procedures have been presumed to produce aerosols and because case-control studies from SARS-CoV-1 reported associations between these procedures and health care worker infections.1Tran K. Cimon K. Severn M. Pessoa-Silva C.L. Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review.PLoS One. 2012; 7e35797Crossref PubMed Scopus (1269) Google Scholar CDC and WHO also recommend conducting aerosol-generating procedures in negative-pressure rooms with high air turnover whenever possible to minimize the amount of infectious aerosols in the room and to prevent their spread outside the room. Determining which procedures belong on lists of aerosol-generating procedures has been contentious.2Rhee C. Baker M.A. Klompas M. The COVID-19 infection control arms race.Infect Control Hosp Epidemiol. 2020; 41: 1323-1325Crossref PubMed Scopus (15) Google Scholar Hospitals and public health authorities created lists of presumed aerosol-generating procedures early in the pandemic, based on very little evidence. Specialties jockeyed to have “their” procedures included in the lists, often with no more evidence than “an abundance of caution.” Hospitals felt compelled to draw the line, particularly early in the pandemic when N95 supplies were scarce, and many therefore excluded coughing, heavy exercise, and labored breathing. In some cases, this led to denying providers access to N95 respirators or negative-pressure spaces when seeing patients with these findings.3Khan S, Tsang KK, Mertz D, et al. A regional Canadian expert consensus on recommendations for restoring exercise and pulmonary function testing in low and moderate-to-high community prevalence coronavirus disease 2019 (COVID-19) settings. Infect Control Hosp Epidemiol. 2020;Nov 20:1-3.Google Scholar The wealth of data generated by the pandemic has now made it clear that just about all the preceding assumptions were wrong. The distinction between droplet- and aerosol-based transmission is artificial and misleading. People routinely produce respiratory particles in a continuum of sizes.4Chen W. Zhang N. Wei J. Yen H.L. Li Y. Short-range airborne route dominates exposure of respiratory infection during close contact.Building and Environment. 2020; 176: 106859Crossref Scopus (222) Google Scholar Most are in the aerosol range, but there is no clear dividing line between droplets and aerosols. Respiratory particles of all sizes can potentially carry all types of respiratory viruses and infect others.5Leung N.H.L. Chu D.K.W. Shiu E.Y.C. et al.Respiratory virus shedding in exhaled breath and efficacy of face masks.Nat Med. 2020; 26: 676-680Crossref PubMed Scopus (1442) Google Scholar A surgical mask alone does not provide adequate protection against infection.6Klompas M. Baker M.A. Griesbach D. et al.Transmission of SARS-CoV-2 from asymptomatic and presymptomatic individuals in healthcare settings despite medical masks and eye protection.Clin Infect Dis. 2021; ([Published online ahead of print March 11, 2021])https://doi.org/10.1093/cid/ciab218Crossref Scopus (34) Google Scholar,7Klompas M. Baker M.A. Rhee C. et al.A SARS-CoV-2 cluster in an acute care hospital.Ann Intern Med. 2021; 174: 794-802Crossref PubMed Scopus (88) Google Scholar Most of the procedures on so-called aerosol-generating procedure lists do not generate aerosols—the risk of infection associated with these procedures is more likely attributable to patient and provider factors (viral load, symptoms, proximity, and duration of exposure) rather than to the procedures themselves.8Klompas M. Baker M. Rhee C. What is an aerosol-generating procedure?.JAMA Surg. 2021; 156: 113-114Crossref PubMed Scopus (94) Google Scholar Two new studies in this issue of CHEST shed further light on aerosol generation and mitigation, particularly in the context of exercise and labored breathing.9Sajgalik P. Garzona-Navas A. Csécs I. et al.Characterization of aerosol generation during various intensities of exercise..Chest. 2021; 160: 1377-1387Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 10Garzona-Navas A. Sajgalik P. Csécs I. et al.Aerosols generated during exercise testing with a portable high-efficiency particulate air filter with fume hood..Chest. 2021; 160: 1388-1396Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Dr Sajgalik and colleagues9Sajgalik P. Garzona-Navas A. Csécs I. et al.Characterization of aerosol generation during various intensities of exercise..Chest. 2021; 160: 1377-1387Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar arranged for eight healthy subjects to undergo a graded-intensity ride on a stationary bicycle within a small, enclosed space with no air turnover. They documented an exponential increase in aerosols with increasing exercise intensity, reaching about 30-fold more aerosols at peak vs baseline. Further key insights included the following: (1) the quantity of small aerosols increased at a greater rate than that of larger respiratory particles; (2) the concentration of aerosols was similar throughout the enclosed space, including behind the test subject; and (3) aerosol generation rates varied substantially between subjects. The same group then evaluated the utility of adding portable high-efficiency particulate absorbing (HEPA) filters to mitigate aerosol concentrations during exercise.10Garzona-Navas A. Sajgalik P. Csécs I. et al.Aerosols generated during exercise testing with a portable high-efficiency particulate air filter with fume hood..Chest. 2021; 160: 1388-1396Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Placing a portable HEPA filter into their exercise chamber reduced the peak concentration of aerosols during exercise by 98%, bringing the concentration down to essentially the same level one would expect in the absence of exercise. Likewise, they showed that adding a HEPA filter to a clinical exercise laboratory with 9 to 12 air changes per hour could reduce the time needed to clear 99.9% of an artificially generated aerosol cloud from approximately 20 minutes to 10 minutes. These two studies clearly demonstrate that heavy exercise is indeed aerosol-generating. The investigators only studied healthy subjects, so they were unable to prove that these aerosols carry virus or that they increase infection risk, but the observation that intense exercise generates large amounts of aerosols helps to explain multiple large clusters of SARS-CoV-2 infections associated with fitness centers, cycling classes, and sports events.11Lendacki F.R. Teran R.A. Gretsch S. Fricchione M.J. Kerins J.L. COVID-19 outbreak among attendees of an exercise facility—Chicago, Illinois, August-September 2020.MMWR Morb Mortal Wkly Rep. 2021; 70: 321-325Crossref PubMed Scopus (37) Google Scholar,12Chu D.K.W. Gu H. Chang L.D.J. et al.SARS-CoV-2 superspread in fitness center, Hong Kong, China, March 2021.Emerg Infect Dis. 2021; ([Published online ahead of print May 18, 2021])https://doi.org/10.3201/eid2708.210833Crossref Scopus (18) Google Scholar Simultaneously, the second study suggests a practical strategy to mitigate the risk of aerosol transmission to health care workers and to patients that might have to enter a room immediately after a patient who has been exercising, namely, adding a portable HEPA filter. We further recommend that providers wear N95s or equivalent respirators during exercise testing when the community incidence of SARS-CoV-2 is high, particularly when seeing untested patients. More broadly, we believe the principles highlighted by these two studies apply beyond the exercise laboratory to the general care of patients with any possible or confirmed respiratory viral infection. These studies affirm the dominant role of aerosols in human respiratory emissions and the outsized role of rapid and labored breathing in increasing aerosol generation. The amount of aerosols produced by heavy breathing and coughing far exceeds the marginal amounts generated by intubation, noninvasive positive-pressure ventilation, and high-flow nasal cannula.13Wilson N.M. Marks G.B. Eckhardt A. et al.The effect of respiratory activity, non-invasive respiratory support and facemasks on aerosol generation and its relevance to COVID-19.Anaesthesia. 2021; ([Published online ahead of print March 20, 2021])https://doi.org/10.1111/anae.15475Crossref Scopus (71) Google Scholar,14Brown J. Gregson F.K.A. Shrimpton A. et al.A quantitative evaluation of aerosol generation during tracheal intubation and extubation.Anaesthesia. 2021; 76: 174-181Crossref PubMed Scopus (118) Google Scholar The implication is that N95s and negative-pressure rooms should be prioritized based on patients’ viral load, symptoms, and activities rather than on the basis of procedures. We further advocate N95s or their equivalents to care for all patients with possible or confirmed respiratory viruses, because all respiratory viruses are carried by aerosols, not just SARS-CoV-2.5Leung N.H.L. Chu D.K.W. Shiu E.Y.C. et al.Respiratory virus shedding in exhaled breath and efficacy of face masks.Nat Med. 2020; 26: 676-680Crossref PubMed Scopus (1442) Google Scholar The COVID-19 pandemic has been revolutionary in so many respects, but one clear benefit has been the wealth of studies that have refined our understanding of respiratory physiology and how it contributes to viral transmission. We must now take this knowledge and use it to better protect health care workers and patients against all respiratory viruses. /cms/asset/af6a97da-810a-49cd-ba43-405484f338da/mmc1.mp3Loading ... Download .mp3 (35.48 MB) Help with .mp3 files Audio Characterization of Aerosol Generation During Various Intensities of ExerciseCHESTVol. 160Issue 4PreviewOur data suggest exercise testing is an aerosol-generating procedure and, by extension, other activities that involve exercise intensities at or above 50% of predicted heart rate reserve. Results can guide recommendations for safety of exercise testing and other indoor exercise activities. Full-Text PDF Mitigation of Aerosols Generated During Exercise Testing With a Portable High-Efficiency Particulate Air Filter With Fume HoodCHESTVol. 160Issue 4PreviewThe portable HEPA filter reduced the concentration of aerosols generated during exercise testing by 96% ± 2% for all particle sizes and reduced aerosol room clearance time in clinical exercise testing laboratories. Portable HEPA filters therefore might be useful in clinical exercise testing laboratories to reduce the risk of COVID-19 transmission. Full-Text PDF" @default.
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