Response to: Respiratory protection for airway operators – Response to “aerosol generation during percutaneous tracheostomy insertion”

Ramesh AV, Collin I, Gregson FKA, Brown J. “Aerosol generation during percutaneous tracheostomy insertion. Journal of the Intensive Care Society, 6.12.2020, doi.org/10.1177/1751143720977278

We would like to commend Ramesh et al on their interesting article, investigating the generation of particles during a percutaneous tracheostomy in a patient under general anaesthesia. The findings in this context may be of great importance in understanding the transmissibility of COVID-19 during surgical airway procedures and the potential occupational hazards for ENT surgeons, intensivists and anaesthetists. The authors demonstrate that real time particle measurements might be a useful tool for environmental monitoring during surgical airway management and thereby offer valuable insights in risk assessment and required infection control measures. After presenting this single case study the authors conclude that on this basis tracheostomy insertion and bronchoscopy in paralysed patients may not need to be considered “aerosol generating procedures”. That said we have some queries about the generalisability of the findings, especially if the used method is sufficient to determine the transmissibility of SARS-CoV-2 or its new variant VUI-202012/01.

It has been well established that health care workers are not only at a much higher risk of contracting COVID-19^1,2 but also to experience more severe courses of the disease. ³ Head and Neck Surgery’s national body (ENT UK) became aware from experience in China and Italy that COVID-19 posed a special threat to otolaryngologists–head and neck surgeons ⁴ and have therefore, in line with Public Health England, recommended enhanced respiratory protection (FP3 masks or PAPRs) during routine procedures of the upper airway as well as tracheotomies, as these could transmit high viral loads to clinicians. ⁵

Ramesh and co-workers describe a case of a patient who was fully anaesthetised and paralysed in an operating theatre. However, the same procedure might expose staff working in relatively “still air” environments like an ICU to a very different risk. Therefore, although these findings are highly relevant for airway operators, may need to be tested in a range of clinical settings and patient populations to be generalisable. We are not certain that the authors definitively demonstrate that aerosol precautions are no longer required during surgical airway procedures in SARS-CoV-2 positive patients.