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IICMS – Position Statement Regarding The Use Of Personal Protective Equipment For Respiratory Physiologists Performing Pulmonary Function Tests During COVID-19 Pandemic.

IICMS – Position Statement regarding the use of Personal Protective Equipment for Respiratory Physiologists performing pulmonary function tests during COVID-19 pandemic.

Position Statement regarding the use of Personal Protective Equipment for Respiratory Physiologists performing pulmonary function tests during COVID-19 pandemic.

27th August 2020

 

The IICMS Faculty of Respiratory holds the position that many standard pulmonary function tests are aerosol generating procedures (AGP). All patients presenting for pulmonary function tests should be treated as potentially infectious due to delayed symptoms, in pre-symptomatic and asymptomatic patients. Full PPE should therefore be applied by all Physiologists when testing patients. All testing rooms should have the facilities to manage aerosol generating procedures.

 

Current HSE guidance for AGPs in the management of Covid-19 does not acknowledge pulmonary function tests as an AGP

 

SARS-Cov-2 is primarily transmitted through respiratory droplets or contact1. In addition, there is an increased risk of transmission associated with some healthcare procedures that produce very small droplet sizes (<5microns) that can be suspended in the air and travel over distance and have the ability to infect if inhaled. These procedures are termed aerosol generating procedures (AGP).

 

There is no current consensus internationally on a definitive list of healthcare procedures that are AGPs. Thus as stated by the Centres of Disease Control and Prevention:

‘there is neither expert consensus, nor sufficient supporting data, to create a comprehensive list of AGPs for healthcare settings’2.

The HSE guidance for AGPs does not classify pulmonary function tests as an AGP3. The evidence to support the classification of AGPs is mainly based on case-control and retrospective cohort studies on a selection number of high risk healthcare procedures during the SARS outbreak4. Pulmonary function testing has not been explicitly investigated in the context of COVID-19. The consensus among professional respiratory societies both nationally 5,6  and nationally7 is to treat pulmonary function testing as an AGP until there is conclusive scientific evidence to prove otherwise.

 

Pulmonary Function tests

Patients perform maximal expiratory manoeuvres during pulmonary function tests that can induce cough, sputum production and throat clearing. Droplets emitted during coughing are an important route for virus transmission8. Coughing induced by PFTs may be forceful, prolonged and not easily suppressed. Clinically many patients presenting for PFT’s are predisposed to coughing due to their underlying health condition e.g. COPD, CF, Bronchiectasis. Patients cannot wear masks during the tests which increases the risk of droplets being dispersed into the room.

In addition, it is not possible for a respiratory physiologist to maintain a distance of 2 metres from the patient during the tests. Exposure time for the physiologist can vary from 30-90 minutes depending on the tests being performed.

The IICMS Faculty of Respiratory acknowledges that there is not conclusive evidence linking pulmonary function testing with a higher risk of SARS-CoV-2 transmission but neither is there evidence that it is completely safe. Due to inherent risks involved in pulmonary function testing, the IICMS Faculty of Respiratory recommends that physiologists wear the following PPE consistent with the recommendation for aerosol generating procedures:

  • FFP2 or FFP3 respirator mask
  • Long sleeved gown
  • Face shield or eye protection
  • Gloves

 

 

 

 

 

 

 

PFTs should ideally be performed in a negative pressure or neutral pressure room, in-line with the recommendations for aerosol generating procedures3. If a negative/neutral pressure room is not available, PFTs should be undertaken in a well-ventilated single room, with the door kept closed, strictly away from other patients and staff, with post-test downtime strictly adhered to.  The clearance of particles in the air after an AGP is dependent on the number of air exchanges in the room. The time taken for 99% of the air particles to be cleared is directly related to the time the room should be left before cleaning after an AGP (from the table below)2. The laboratory should have sufficient air exchanges to reduce the downtime to a minimum.

 

 

 

Temperature control is an important and critical component must be provided in conjunction with the fresh air exchange unit.  Lung function tests are only clinically valid if the tests are recorded within a pre-test strict calibration range (dependent on room temperature, barometric pressure and humidity).  Any fluctuations will lead to significant measurement errors and seem the measurement invalid.  Ultimately this will impact of patient care so is not acceptable.

References

  1. Modes of transmission of virus causing COVID-19 implications for IPC precaution recommendations. World Health Organisation (WHO).https://www.who.int/news-romm/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations. WHO 2020 (20 May 2020)

 

  1. US Centre for Disease Control- Guidelines for Environmental Infection Control in Health-Care Facilities 2003 https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html

 

  1. HSE/HSPC Infection Prevention and Control Precautions FOR Possible or Confirmed COVID-19 in a Pandemic Setting. V1.1 May 8th 2020

 

  1. Tran et al. Aerosol generating procedures and risk transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One, 2012;7(4). Doi:10.1371/journal.pone0035797

 

  1. ATS Restoring Pulmonary and Sleep services as the COVID-19 Pandemic lessens: From an Association of Pulmonary, Critical Care and Sleep Division Directors and American Thoracic Society co-ordinated Task Force. 10.1513/AnnalsATS.202005-514ST July 2020

 

  1. ERS Group 9.1-Lung Function testing and beyond: May 2020

 

  1. ITS/IIMCS Guidance on Lung Function Testing-SARS COVID-19 Infection V3: May 2020

 

  1. Dhand et al. Coughs and sneezes. Their role in transmission of Respiratory Viral infections including SARS-CoV-2. American Journal of Resp and Critical Care Medicine

http://doi.org/10.1164/rccm.202004-1263PP

 

 

 

 

 

 

 

 

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