www.aana.com/aanajournalonline AANA Journal February 2021 Vol. 89, No. 1 71

The ongoing coronavirus disease 2019 (COVID-19)

pandemic has created many changes and difficulties

in healthcare, and the anesthesia specialty is no excep-

tion. Both the increased need for personal protective

equipment (PPE) and the potential for infection and

contamination through respiratory droplets have been

sources of much concern. Policies and protocols have

been adapted worldwide to help neutralize infection

risk and exposure. Transmission of the virus to health-

care workers has been a major concern, and the risk of

infection is exceptionally high for Certified Registered

Nurse Anesthetists (CRNAs) because of their close

contact with infected patients. CRNAs are in a unique

position to help decrease exposure for themselves

and other members of the healthcare team by taking

extra precautions during airway manipulation. A great

deal of focus has been placed on reducing risks during

intubation, but reports describing methods of reducing

contamination and exposure to respiratory droplets

during emergence and extubation are scarce. The

authors have reviewed techniques to reduce cough-

ing, thereby decreasing the potential of virus exposure

through contact with large respiratory droplets and

aerosolized particles that may remain suspended in air.

Keywords: Certified Registered Nurse Anesthetist,

coughing, COVID-19, deep extubation.

Methods to Reduce the Risk of Exposure to Airborne Pathogens in the Operating Room

Dwayne Accardo, DNP, CRNA

Jordan Isaac, DNP, CRNA

Peter Strube, DNAP, CRNA, MBA, MSNA, APNP, APRN, LTC(ret)

Michael MacKinnon, DNP, FNP-C, CRNA

Cindi Dabney, DNP, CRNA

The coronavirus disease 2019 (COVID-19) pan-demic has changed the landscape of anesthesia and forced Certified Registered Nurse Anes-thetists (CRNAs) to rethink their anesthetic management of cases. At the forefront of this

change is the availability of personal protective equipment (PPE). Because of the increased need to conserve sup-plies because of limited availability, healthcare providers often must cope with cleaning, resterilizing, and reusing PPE. When caring for patients who have a positive test result for COVID-19 (“COVID-19 positive”), healthcare providers require full PPE (including eye protection, face shields, gloves, and FFP3 or N99 respirators); similarly, when aerosol-generating procedures are performed, pro-tective equipment such as powered air-purifying respira-tor hoods and waterproof gowns are necessary.1 Because of shortages in PPE supply as well as implementing extended-use protocols for masks, respirators, goggles, face shields, gowns, and gloves, it is imperative that CRNAs take an active role in reducing COVID-19 expo-sure and contamination in the perioperative environment.

Many patients are COVID-19 positive yet remain asymptomatic. Therefore, CRNAs must assume all un-tested patients are infected, especially when performing aerosol-generating procedures such as intubation and extubation. Currently, the Centers for Disease Control and Prevention’s (CDC) COVID Data Tracker reports

that more than 3.1 million Americans have been infected and an excess of 265,000 deaths have occurred due to COVID-19 as of November 2020.2 Furthermore, the number of COVID cases globally has surpassed 62.3 million, with an estimated death rate approaching1.5 million people.3 The World Health Organization (WHO) has recommended the number of operating room staff be kept to a minimum when these procedures are being performed.4 Similarly, the American College of Surgeons has recommended that personnel who are not directly involved with airway management remain outside the operating room during intubation and extubation.5 The benefit of having personnel to wait outside the operating room is that they can be quickly notified if additional airway assistance is required.

Transmission of the virus occurs through respiratory droplets, which can affect healthcare providers at dispro-portionate rates; therefore, to help decrease unnecessary exposure, it is advisable to minimize the number of staff present during occurrences when airborne transmis-sion of the virus is high.6-8 Healthcare experts currently recommend surgical staff not to be present when intuba-tions or extubations are performed, entering or leaving the operating room should be kept to a minimum, and disinfection should not begin until after 15 minutes have passed following the patient’s departure.1,9

Although much of the literature indicates that COVID-

72 AANA Journal February 2021 Vol. 89, No. 1 www.aana.com/aanajournalonline

19 is spread by respiratory droplets, recent findings have shown that COVID-19 can also be spread by aerosol.8,10 Most airborne pathogens fall into the fine particle or ultrafine particle category and can remain suspended in air for days or even weeks.11 According to the American Society of Anesthesiologists Committee on Occupational Health, an airborne infection isolation room with nega-tive pressure and at least 6 air changes per hour should be used for patients who have COVID-19.12 Additionally, air from these rooms should be directly vented to the outside atmosphere, or a high-efficiency particulate air (HEPA) filter should be used before recirculation.12

Potential causes of respiratory droplet exposure include saliva spray during positive pressure ventilation and the passive expiration that follows, during coughing, or during any placement or removal of airway equipment that mobilizes sputum in the operating room. It is in-cumbent on CRNAs to minimize any forceful movement of air from the patient to decrease the risk of airborne ex-posure to either themselves or any other operating room personnel involved in the care of these patients. Several methods are available that CRNAs can use to decrease risk of exposure to airborne pathogens in the operating room, but the most notable method is a modified rapid sequence induction to avoid positive pressure ventilation and forceful passive expiration. Although guidelines have continually evolved during the COVID-19 pandemic, the use of clear drapes, intubation shields, and video laryngoscopy has been advocated during induction and intubation. However, reports focusing on emergence and extubation techniques during the pandemic have been elusive. Emergence from anesthesia is another opportu-nity for airborne pathogen exposure, especially if accom-panied by excessive coughing and spewing of secretions from the nasal and oral pharynx. When the patient meets qualifying criteria, the CRNA can perform a deep extu-bation and greatly reduce the risk of airborne pathogen exposure to healthcare providers during the patient’s emergence from anesthesia.

History and Review of Literature• Coronavirus Recognition and Transmission. In their early 2019 report, Wang and colleagues6 detailed the clinical characteristics of hospitalized patients in Wuhan, China, who were infected with the severe acute respirato-ry syndrome coronavirus-2 (SARS-CoV-2), the virus that causes COVID-19, and in whom pneumonia subsequent-ly developed. Initially, characteristics of the disease were limited, as the infection rapidly spread through humans who were in close contact or in cluster groups. The out-break of infections was quickly recognized international-ly, with signs and symptoms including fever, dry cough, muscle pain, fatigue, leukopenia, pneumonia, cardiogen-ic shock, cardiac and renal injury, acute respiratory dis-tress syndrome (ARDS), and death. The CDC identified

older adults and people with certain medical conditions, such as cancer, chronic kidney or liver disease, chronic obstructive pulmonary disease, immunocompromised state, obesity, heart conditions, sickle cell disease, diabe-tes, asthma, hypertension, pregnancy, and smoking, as being at an increased risk of becoming sick with severe COVID-19 illness. Also according to the CDC, those who need to take extra precautions include racial and ethnic minority groups, rural community residents, those with developmental disorders, and the homeless population.13 The virus is similar to SARS and Middle East respiratory syndrome (MERS). Bats have been believed to be the primary source. Although the origination of the virus is still under investigation, current evidence suggests the spread to humans occurred via transmission from wild animals sold illegally in the Huanan Seafood Wholesale Market in Wuhan, China.14 On January 1, 2020, the Chinese government temporarily closed the market after identifying it as a source of COVID-19.14 On January 26, 2020, China banned the sale and consumption of wild animals as a food source.14 Thereafter, the director of the wildlife trade monitoring organization, Xu Ling, reported the market remained closed.14

One important factor that influences how society and healthcare professionals manage risk is understanding the modes of COVID-19 transmission. Although it is clear that person-to-person contact is the primary means of transmission today, this understanding is incomplete, as other variables may contribute as well. The WHO began establishing guidelines for infection prevention and control of virus spread based on information gath-ered related to MERS and SARS, and the organization continues to update its guidelines and information about COVID-19.4 These guidelines include early triage and recognition of infections; assurance of safety measures for all patients; and methods to properly observe droplet and airborne precautions, especially when aerosol-gener-ating procedures are performed. The WHO also advises on administrative and environmental controls, handling of specimens, and care for outpatients.4 Current data from the CDC suggest that infection occurs from close contact and mainly through respiratory droplets from an infected individual; hence, when an infected individual coughs, sneezes, or talks within about 1.8 m (6 ft), drop-lets can make direct contact with the mucous membranes in the mouth, eyes, or nose, potentially leading to infec-tion.15 Additionally, infection can occur if an individual touches mucous membranes after getting virus particles on his or her hands in some manner.

The ability for COVID-19 to be transmitted via aerosols or droplet nuclei that remain in the air over distance and longer times is a controversial issue. An April 16, 2020, letter to the New England Journal of Medicine editor indi-cated that COVID-19 remained viable in artificial aerosol for up to 3 hours and was stable on plastic and stainless

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steel for 3 days, thereby suggesting the high probability of a super spread of the virus in pandemic proportions.8

Guan and colleagues10 described how the virus spread so quickly through China and assimilated data from more than 1,000 patients to describe clinical characteristics of those infected. In addition, results from 3 different studies showed viral RNA in the air of rooms housing COVID-19–positive patients but did not determine if the particles were enough to cause infection.16-18 Still, results from 3 additional studies suggested droplets may travel farther than the aforementioned 1.8 m (6 ft) during instances of speaking, coughing, or sneezing.18-21 The implications of these findings are unclear, but to date, studies that identify infections contracted from respiratory droplets in greater than 1.8 m (6 ft) have yet to be published.22

In a letter to the editor of Lancet, Lu et al7 explained that infection through the ocular membranes had been largely overlooked and, noting that this could be a possible source of infection, emphasized the importance of eye pro-tection while caring for infected patients. As reported by Zimmermann and Nkenke,1 it is important to review the possible sources of infection through mucosal membranes, emphasize the likelihood of spread of virus through oral and maxillofacial surgery, and recognize that all of these cases should be characterized as high-risk for COVID-19 transmission. Large droplet contamination is the primary source of infection, but according to Ereth et al,11 fine and ultrafine particle contamination is also a possibility for several days or weeks due to suspension in air.

Although it is difficult to assess the risk for CRNAs and other professionals who are in close proximity to and are manipulating or instrumenting the airway of patients with COVID-19, close contact appears to be a high-risk factor due to the proximity of high viral load.23-26 Furthermore, it has been well documented that tracheal intubation, a commonly performed anesthesia procedure, is a high risk for producing droplets and/or aerosols.27,28

Compounding the risk of exposure to healthcare pro-viders who are treating patients with known COVID-19 is the risk of close interaction with asymptomatic viral-shedding patients, which also has been reported in numer-ous study findings.29-33 These individuals are within the incubation period and have had upper respiratory tract swab tests positive for SARS-CoV-2 from 1 to 6 days before symptoms.34,35 Investigators have also found that SARS-CoV-2 can remain on surfaces in the hospital rooms of pa-tients with COVID-19 between 6 and 9 days, but this has yet to be shown to equate to infection risk for others.14,36,37 A portion of the literature review encompassed under-standing the manner in which virus is spread.

Measures that CRNAs can take to diminish COVID-19 spread include minimizing forceful exhalation and coughing during airway intubation and extubation. Wax et al23 reviewed comprehensive precautionary measures for the induction phase of anesthesia to decrease cough-

ing and potential virus spreads through respiratory drop-lets.35-37 Asouhidou and Trikoupi38 demonstrated the advantages of decreasing sympathetic outflow related to blunting responses to noxious stimuli. Mechanisms and techniques for deep extubation and helpful medications to decrease airway stimulation and coughing were also noted in prior research findings.39

Discussion of State of the ArtEven in non-COVID-19 situations, intubation and extu-bation are already extremely challenging and taxing. The risk of COVID-19 exposure adds an additional stressful layer during direct patient care. To decrease exposure to COVID-19, providers should conduct high-risk pro-cedures such as intubation and extubation in negative pressure airflow rooms.23 Wax et al23 described practice recommendations for intubations during the COVID-19 pandemic but did not address extubation. Every effort and consideration should be employed to decrease the risk of aerosolizing particles during intubation and ex-tubation. Many reports are available that address intuba-tion, but reports that focus on extubation have proved difficult to find. Therefore, the following recommenda-tions are suggested to decrease the risk of exposure to anesthesia providers and perioperative staff during the extubation phase of patients with COVID-19.

The incidence of coughing on emergence from anes-thesia is distressingly high.38 The return to protective reflexes, in conjunction with generalized awareness and perception of the endotracheal (ET) tube, create a perfect environment to expose anesthesia providers and sur-rounding personnel to the aerosolized SARS-CoV-2 virus.

Deep extubation, a technique used to minimize or prevent patients from coughing during emergence from anesthesia, involves the removal of the ET tube while the patient is still fully anesthetized. Extubation of a deeply anesthetized or sedated patient routinely produces a smooth emergence without laryngospasm or an excite-ment phase that would be consistent with the traditional description of “Stage 2” anesthesia.39 Surgeons will oc-casionally request that the patient not cough for surger-ies such as anterior cervical disc fusion, hernia repairs, cranial surgery, middle ear procedures, or any case in which wound dehiscence is a concern. Smooth, well-con-trolled extubation reduces coughing, expectoration, and the unnecessary exposure of operating room personnel and intensive care personnel to aerosolized, potentially infectious airway secretions.39

Contraindications to this technique include a nonfast-ing state, achalasia, difficult airway, gastric outlet obstruc-tion or bowel obstruction, gastroparesis, ileus, impaired swallowing, morbid obesity, and pregnancy.39 Before ex-tubation of patients with COVID-19, all personnel who are not actively participating in airway management should remain outside the operating room with a runner dressed

74 AANA Journal February 2021 Vol. 89, No. 1 www.aana.com/aanajournalonline

in full PPE to retrieve additional supplies and equipment. For all personnel within 2 m of the patient, full PPE with a powered air-purifying respirator is worn.40 Just like all aspects of anesthesia, there are many ways to provide an anesthetic, and it is very likely that each individual provider has his or her own methods. The authors have outlined the following suggestions to assist those who are less familiar with the technique of deep extubation.

The first task is to ensure that the patient’s secre-tions are suctioned from the airway. If secretions are left behind, they can stimulate the airway and lead to a laryn-gospasm. Consider using an antisialagogue such as gly-copyrrolate if not contraindicated. The patient must also be adequately anesthetized, or the CRNA risks the patient being stimulated, which could possibly lead to coughing or laryngospasm. The stimulation caused by suctioning the patient can provide further context to the depth of the patient’s anesthetic. The patient’s anesthetic also should be fully reversed and devoid of residual muscle re-laxation. If any other gas mixtures such as air or nitrous oxide were being used, they should be discontinued, thus giving the patient 80% to 100% oxygen, depending on the patient’s respiratory status. After the patient begins to breathe spontaneously, the respiratory rate will give the CRNA an indication that the patient is adequately anes-thetized. After the CRNA is satisfied with the depth of anesthesia provided by the volatile agent and level of nar-cotic, the cuff of the ET tube should be slowly deflated. If an oral airway is not in place, consider placing one at this point. Turn the anesthetic gas off and fresh gas flows up. As the patient takes a breath in, the ET tube should be gently removed. Patients will often breath-hold following deep extubation and need to be given up to 30 seconds to resume spontaneous respirations.41 Risk factors with deep extubation include coughing, sore throat, hypoven-tilation, airway obstruction, hypoxia, increased blood pressure, decreased cardiac ejection fraction, increased ventilation/perfusion mismatch, and regurgitation.42

ConclusionProviding safe and effective anesthesia care for every patient is the primary focus of CRNAs.43 Since the arrival of the novel coronavirus, many new protocols have been developed worldwide to contain its spread by way of re-spiratory droplets. As CRNAs, we can help reduce expo-sure to the virus for ourselves and our perioperative part-ners by enacting measures to decrease direct contact from large droplets or aerosolized particles that can remain suspended in air. Much attention has been directed to decreasing exposure during intubation, but methods to reduce infection during extubation have not been pre-viously reported. Incorporation of methods to reduce coughing on emergence and use of deep extubation tech-niques have the potential to become important weapons in our arsenal against the spread of this deadly disease.

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AUTHORSDwayne Accardo, DNP, CRNA, is an assistant professor and program director, Nurse Anesthesia Concentration, University of Tennessee Health Science Center, College of Nursing, Memphis, Tennessee. Email: dac-cardo@uthsc.edu.

Jordan Isaac, DNP, CRNA, is an assistant professor at the University of Tennessee Health Science Center, College of Nursing.

Peter Strube, DNAP, CRNA, MBA, MSNA, APNP, APRN, LTC(ret), is an assistant program director, Nurse Anesthesia Program at the University of Wisconsin, Oshkosh, Wisconsin.

Michael MacKinnon, DNP, FNP-C, CRNA, is an associate professor and assistant program director, National University, Fresno, California. Email: Mmackinnon@nu.edu.

Cindi Dabney, DNP, CRNA, is an assistant professor at the University of Tennessee Health Science Center, Memphis, Tennessee.

DISCLOSURES The authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did not discuss off-label use within the article. Disclosure statements are available for viewing upon request.

ACKNOWLEDGMENTSThe authors would like to thank Curtis Roby, MA, for his editorial assis-tance in the preparation of this manuscript.

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