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Respiratory protection among healthcare workers during cardiopulmonary resuscitation in COVID-19 patients

      Keywords

      To the Editor:
      We have read with great interest the article Hwang et al. [
      • SY1 Hwang
      • H2 Yoon
      • Yoon A.
      • et al.
      N95 filtering facepiece respirators do not reliably afford respiratory protection during chest compression: a simulation study.
      ]. Although this is a simulation study, it shows that the N95 respirator did not provide adequate protection against respiratory infections during chest compression. The current SARS-CoV-2 pandemic poses a significant challenge for medical personnel, especially in the field of emergency medicine [
      • Wang X.
      • Pan Z.
      • Cheng Z.
      Association between 2019-nCoV transmission and N95 respirator use.
      ]. Following its initial outbreak on December 31, 2019, in Wuhan, a central city in China, COVID-19 has spread around the globe affecting almost all countries. It has been declared a pandemic, and it has infected over 2,790,986 people in a short time, with 196,920 deaths (April 24, 2020), which indicates its high virulence. The emergency staff working at the frontlines of this virus are the most vulnerable, and in the present situation, treat every patient as being potentially infected by the coronavirus. This is especially critical considering the transmission of SARS-CoV-2 is presumed to occur mainly through respiratory droplets generated by coughing and sneezing, by direct contact with contaminated surfaces, and because in a large number of patients COVID-19 disease may be asymptomatic [
      • Dzieciatkowski T.
      • Szarpak L.
      • Filipiak K.J.
      • et al.
      COVID-19 challenge for modern medicine.
      ].
      As recommended by the CDC for aerosol-generating procedures (AGP), medical personnel should be equipped with full personal protective equipment (PPE) for AGP. Currently, there are conflicting reports on protection against the infection while wearing N95 respirators. They undoubtedly protect more than cloth masks or medical masks [
      • Szarpak L.
      • Smereka J.
      • Filipiak K.J.
      • Ladny J.R.
      • Jaguszewski M.
      Cloth masks versus medical masks for COVID-19 protection.
      ]. However, to additionally protect the rescuer during the CPR procedures, the use of face shields covering the entire face is also recommended, apart from using fitted N95 respirators - preferably equipped with FFP3 class filters [
      • Smereka J.
      • Ruetzler K.
      • Szarpak L.
      • et al.
      Role of mask/respirator protection against SARS-CoV-2.
      ]. Then the risk of face contamination, including the mucosa, is much lower. The above is particularly vital in case of inadequate fitting of N95 respirators due to the improper placement or the inability to fit due to facial hair.
      To reduce the risk of the spread of SARS-CoV-2 during CPR, it is good practice to intubate the patient as soon as possible to fully isolate the airway, thus reducing the formation of a potentially dangerous aerosol. We should, moreover, remember that in a hospital setting, all aerosol-generating procedures should be done in an airborne infection isolation room.
      In summary, medical personnel should use full personal protective equipment for aerosol-generating procedures when performing COVID-19 CPR in suspected/confirmed patients. Limiting protection strictly to the use of an N95 respirator as a respiratory protection device is a mistake that may result in an increased risk of infection among medical personnel.

      Declaration of competing interest

      The authors declare that they have no conflict of interest.

      References

        • SY1 Hwang
        • H2 Yoon
        • Yoon A.
        • et al.
        N95 filtering facepiece respirators do not reliably afford respiratory protection during chest compression: a simulation study.
        Am J Emerg Med. 2020 Jan; 38: 12-17https://doi.org/10.1016/j.ajem.2019.03.041
        • Wang X.
        • Pan Z.
        • Cheng Z.
        Association between 2019-nCoV transmission and N95 respirator use.
        J Hosp Infect. 2020; S0195-6701: 30097-30099https://doi.org/10.1016/j.jhin.2020.02.021
        • Dzieciatkowski T.
        • Szarpak L.
        • Filipiak K.J.
        • et al.
        COVID-19 challenge for modern medicine.
        Cardiol J. 2020 Apr 14; https://doi.org/10.5603/CJ.a2020.0055
        • Szarpak L.
        • Smereka J.
        • Filipiak K.J.
        • Ladny J.R.
        • Jaguszewski M.
        Cloth masks versus medical masks for COVID-19 protection.
        Cardiol J. 2020 Apr 14; https://doi.org/10.5603/CJ.a2020.0054
        • Smereka J.
        • Ruetzler K.
        • Szarpak L.
        • et al.
        Role of mask/respirator protection against SARS-CoV-2.
        Anesth Analg. 2020; https://doi.org/10.1213/ANE.0000000000004873