Aerosol Generating Procedures

The long awaited clarification on aerosol generating procedures for physical therapists and physical therapist assistants has finally dropped! The APTA just released its professional guidelines for what portions of physical therapist and physical therapist assistant care equates to an aerosol generating procedures, therefore requiring increased PPE for procedure performance to ensure clinician safety. On April 13, 2020, the Centers for Disease Control (CDC)  updated their guidance to indicate that aerosol generating procedures (AGPs) are medical procedures that are “more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing” and result in “uncontrolled respiratory secretions.” However, exactly what that meant when it came to Physical Therapist services was unclear. Most people, even in the medical world, forget that we do so much more than exercise.

In my Webinar on Combatting COVID, I was very clear that the WCPT guidelines listed exercise as an aerosol generating procedure. However, many healthcare organizations in the United States do not observe the WCPT guidelines, so were defaulting to the CDC guidelines which are silent on “exercise” as a specific term. The CDC guidelines did provide a nice table (which you can view here) that was supposed to guide which level of PPE all healthcare providers should be wearing. But, let’s be real. MOST healthcare providers are not performing the type of work-intensive and time-intensive interventions that we are in the rehab field. Respiratory therapists are definitely taking the brunt of the risk with the number of AGPs they regularly perform. However, many of these don’t take nearly as much time as what we need to perform. Time spent in exposure is one of the most important factors when deciding level of risk involved with a procedure (based on the CDC table mentioned above).

“Mobilization in and out of bed, ambulation, therapeutic exercise, and other similar physical therapist interventions are common procedures performed in intensive care units, hospital wards, inpatient rehabilitation units, other facilities, and patient’s homes. These sessions, which can last 30 minutes or more, result in extensive close body contact; for some procedures PTs and PTAs place their faces within inches of the patient’s face to ensure safety (Loeb, 2004).”

APTA (2020)

But we also need to talk about proximity. When we are transferring a patient, we are ALL UP IN THEIR BUSINESS. We are face to face, we are ear to ear, we are body to body. And for our SLP friends, you are very literally all up in their grill. So proximity increases the risk of allowing droplets to land in your muscosa (ew…). Many healthcare professionals get to stand back and observe, or take vitals using an automated machine and not have to touch. Even starting an IV, you can at least be at arms length. But not while working on perineal hygiene… NOPE. You are well within the danger zone.

And finally, we are making the patient MOVE! We are working them harder than they may have worked in a several days, weeks, or months depending on the setting. We know from recent research that even talking can aerosolize viral particles in to droplet nuclei, so can you just imagine with the huffing and puffing of sit to stands will do? I know people are pretty upset about gyms being closed but, take it from a PT, there is darn good reason for gyms to be closed! You are in a small space with several people (even at 6 feet apart) all huffing and puffing increased lung volumes, forces, and depths, aerosolizing droplet nuclei in clouds, over and over and over again. There is no amount of environmental control that could save you. But, here comes therapy, down the hall in full PPE, ready to work the sickest folks and hang out them in that cloud for 30 minutes or more. So, the obvious answer was yes, therapy interventions OF COURSE are aerosol generating procedures. But you didn’t have to convince us of that…

“Assisting a patient in moving from supine to sitting increases the depth and rate of ventilation, and creates a shift in ventilation and perfusion patterns, in a manner that often elicits uncontrolled respiratory secretions and/or cough reflex. Rolling, proning, and supinating a patient in bed also are considered aerosol-generating procedures.”

APTA (2020)

We don’t really need to just focus on exercise and physical activity. Patients with COVID-19 are critically ill. Many of the patients I see regularly are critically ill because I work with many people who have complex chronic diseases. That means there is a significant likelihood that CPR may be needed at some point in time. I have had plenty of coworkers who have arrived at a home and had to start chest compressions. I’ve been a first responder to so many people just randomly out in public at train stations, sporting events, or even weddings. But then, to add strenuous physical activity on top of a critical illness, we are upping the ante (because that’s what we are trained to do). In the event we do have to perform CPR, if we are not already donned in appropriate PPE, the APTA has made it clear that it takes approximately 6 minutes to do so. That’s 6 minutes our patient goes without oxygen to their brain. That, my friends, is not a patient that will survive. Those 6 minutes are crucial so we need to be ready to go at the onset.

Ultimately, rehab clinicians literally have to do all three things that create the most aerosol AND places the provider at highest risk. Yet there was no clear statement from any agency or authority, only “exercise” listed on the WCPT guidelines. Many saw that as not including physical activity like transfers or bed mobility. Thankfully, ASHA released a document clarifying the provision of Speech-Language Pathologist Services in regards to aerosol-generating procedures to set guidelines for their own profession. So, I (and many others, I’m sure) have just been waiting…

“Across respiratory conditions, mobility and exercise are known to be a form of airway clearance, often resulting in uncontrolled respiratory secretions and bouts of spasmodic coughing (Strickland, 2013).”

APTA (2020)

I hope everyone takes a read on this one, prints it out, takes it to work, posts it in the office, in the hallways, screams it from the mountaintops and whatever you need to do to make sure you get the proper equipment you need to keep yourself safe when treating patients. The highest number of new cases of COVID-19 are among those 20-40 years old. There are many people in the ICU within that age range including several without underlying conditions. I’ve said it before, and I’ll say it again, COVID doesn’t discriminate. Please take necessary precautions and stay safe out there.

Read the original publication here:

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I know it’s been a long time coming, but are you getting the proper PPE yet? Let me know in the comments!

References:

APTA. (2020). Taking Precautions for Mobility and Exercise as Potential Aerosol-Generating Procedures. Retrieved from https://www.apta.org/patient-care/public-health-population-care/infectious-disease-control/precautions-mobility-exercise-potential-aerosol-generating-procedures

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