A quantitative evaluation of aerosol generation from upper airway suctioning during tracheal intubation and extubation sequences.

Abstract

Background: Open respiratory suctioning is considered to be an aerosol generating procedure (AGP) and laryngopharyngeal suction, used to clear secretions during anaesthesia, is widely managed as an AGP. It is uncertain whether such upper airway suctioning should be designated an aerosol generating procedure (AGP) because of a lack of both aerosol and epidemiological evidence of risk. Aim: To assess the relative risk of aerosol generation by upper airway suction during tracheal intubation and extubation in anaesthetised patients. Methods: Prospective environmental monitoring study in ultraclean operating theatres to assay aerosol concentration during intubation and extubation sequences including upper airway suctioning for patients undergoing surgery (n=19 patients). An Optical Particle Sizer (particle size 300nm-10μm) was used to sample aerosol 20cm above the mouth of the patient. Baseline recordings (background, tidal breathing and volitional coughs) were followed by intravenous induction of anaesthesia with neuromuscular blockade. Four periods of oropharyngeal suction were performed with a Yankauer sucker: pre-laryngoscopy, post-intubation and pre- and post-extubation. Findings: Aerosol from breathing was reliably detected (65[39-259] particles.L-1 (median[IQR])) above background (4.8[1-7] particles.L-1, p<0.0001 Friedman). The procedure of upper airway suction was associated with much lower average concentrations of aerosol than breathing (6.0[0-12] particles.L-1, P=0.0007) and was indistinguishable from background (P>0.99). The peak aerosol concentration recorded during suctioning (45[30-75] particles.L-1) was much lower than both volitional coughs (1520[600-4363] particles.L-1, p<0.0001, Friedman) and tidal breathing (540[300-1826] particles.L-1, p<0.0001, Friedman). Conclusion: The procedure of upper airway suction during airway management is associated with no higher concentration of aerosol than background and much lower than breathing and coughing. Upper airway suction should not be designated as a high risk AGP.  

Competing Interest Statement

AEP declares advisory board work for Lateral Pharma and consultancy for and research grants from Eli Lilly for projects unrelated to this study.

Funding Statement

The AERATOR study is registered in the ISRCTN registry (ISRCT:N21447815). Andrew Shrimpton is an NIHR funded doctoral Research Fellow, the MAGPIE study is part of the NIHR301520 grant. AERATOR is funded by an NIHR-UKRI rapid rolling grant (Ref: COV0333). This report presents independent research commissioned by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, UKRI, or the Department of Health.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethical approval was granted by the Greater Manchester REC committee (Reference: 20/NW/0393, approved 18/09/2020) and all patients gave written informed consent. The study was granted Urgent Public Health status by NIHR and is registered in the ISRCTN registry (ISRCT:N21447815).

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Yes

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Data Availability

All data produced in the present study are available upon reasonable request to the authors

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