What therapies are considered Aerosol-Generating Medical Procedures (AGMPs)?

Posted on May 5, 2020 by Ellison Richmond

Summary

According to Ottawa Hospital practice guidlines, the following are AGMPs:

  • Intubation (confirmed)
  • Bronchoscopy (confirmed)
  • Non-invasive positive pressure including BIPAP and CPAP (confirmed)
  • Tracheostomy (confirmed)
  • Trach Hood ventilation (confirmed)
  • Bag-mask ventilation (confirmed)
  • High-flow nasal oxygen therapy – HFNO (inconclusive) – includes the following: Maxtec, Airvo, Nasal prongs (any type) > 6L/min
  • Nebulized aerosol therapy (confirmed)
  • Insufflation-exufflation (IN-EX – confirmed)
  • Lung volume recruitment (LVR – confirmed)

I.   GUIDELINES

  • Public Health Ontario lists the following as procedures generating droplets/aerosols in suspected COVID-19 (25 Mar 2020): (1)
    • Endotracheal intubation, including during cardio-pulmonary resuscitation
    • Cardio-pulmonaryresuscitation during airway management
    • Open airway suctioning
    • Bronchoscopy (Diagnostic or Therapeutic)
    • Autopsy
    • Sputum induction (Diagnostic or Therapeutic)
    • Non-invasive positive pressure ventilation for acute respiratory failure (CPAP, BiPAP3-5)
    • High flow oxygen therapy
  • Ottawa Hospital has COVID-19 oxygen therapy guidelines, including suggested sequence of events and infection control measures. (2)
  • Ottawa Hospital practice guidelines suggest the following are not AGMPs in COVID-19 patients:
    • Nasal cannula up to 6L/min
    • Hi-Ox non-rebreather mask with HEPA filter up to 15L/min
    • Non-rebreather mask with HEPA filter up to 15L/min
  • Ottawa Hospital practice guidelines suggest the following are AGMPs in COVID-19 patients:
    • Intubation (confirmed)
    • Bronchoscopy (confirmed)
    • Non-invasive positive pressure including BIPAP and CPAP (confirmed)
    • Tracheostomy (confirmed)
    • Trach Hood ventilation (confirmed)
    • Bag-mask ventilation (confirmed)
    • High-flow nasal oxygen therapy – HFNO (inconclusive) – includes the following: Maxtec, Airvo, Nasal prongs (any type) > 6L/min
    • Nebulized aerosol therapy (confirmed)
    • Insufflation-exufflation (IN-EX – confirmed)
    • Lung volume recruitment (LVR – confirmed)
  • WHO interim guidance for suspected COVID-19 (3) states “Ensure that health care workers performing aerosol-generating procedures (e.g. open suctioning of respiratory tract, intubation, bronchoscopy, cardiopulmonary resuscitation) use the appropriate PPE, including gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or higher level of protection). A scheduled fit test should not be confused with a user’s’ seal check before each use. Whenever possible, use adequately ventilated single rooms when performing aerosol-generating procedures, meaning negative pressure rooms with a minimum of 12 air changes per hour or at least 160 L/second/patient in facilities with natural ventilation. Avoid the presence of unnecessary persons individuals in the room. Care for the patient in the same type of room after mechanical ventilation begins.”

They also state: “Sputum induction should be avoided owing to increased risk of aerosol transmission” and “Because of uncertainty around the potential for aerosolization, HFO, NIV, including bubble CPAP, should be used with airborne precautions until further evaluation of safety can be completed.”

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

REFERENCES

  1.  Updated IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect or Confirmed COVID-19 Key Findings [Internet]. 2020. Available from: https://www.publichealthontario.ca/-/media/documents/ncov/updated-ipac-measures-covid-19.pdf?la=en
  2.  TOH Covid-19 Clinical Guidelines – Standardizing Oxygen Therapy Practice V1.6 25 March 2020
  3. Clinical management of severe acute respiratory infection when COVID-19 is suspected [Internet]. Who.int. 2018 [cited 2020 Mar 30]. Available from: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.