Aerosol generation with various approaches to oxygenation in healthy volunteers in the emergency department

OBJECTIVES: Health care workers experience an uncertain risk of aerosol exposure during patient oxygenation. To improve our understanding of these risks, we sought to measure aerosol production during various approaches to oxygenation in healthy volunteers in an emergency department. METHODS: This was a prospective study conducted in an empty patient room in an academic ED. The room was 10 ft. long x 10 ft. wide x 9 ft. tall (total volume 900 ft(3)) with positive pressure airflow (1 complete turnover of air every 10 minutes). Five oxygenation conditions were used: humidified high‐flow nasal cannula (HFNC) at 3 flow rates [15, 30, and 60 liters per minute (LPM)], non‐rebreather mask (NRB) at 1 flow rate (15 LPM), and closed‐circuit continuous positive airway pressure (CPAP) using the ED ventilator; in all cases a simple procedural mask was used. The NRB and HFNC at 30 LPM maneuvers were also repeated without the procedural mask, and CPAP was applied both with and without a filter. Each subject then sequentially underwent 8 total oxygenation conditions, always in the same order. Each oxygenation condition was performed with the participant on a standard ED bed. Particles were measured by laser aerosol spectrometer, with the detector sampling port positioned directly over the center of the bed, 0.35 meters away and at a 45‐degree angle from the subject's mouth. Each approach to oxygenation was performed for 10 minutes, followed by a 20‐minute room washout (≈ 2 complete room air turnovers). Particle counts were summated for 2 size ranges (150–300 nm and 0.5–2.0 μm) and compared before, during, and after each of the 8 oxygenation conditions. RESULTS: Eight adult subjects were enrolled (mean age 42 years, body mass index 25). All subjects completed 8 oxygenation procedures (64 total). Mean particle counts per minute across all oxygenation procedures was 379 ± 112 (mean ± SD) for smaller aerosols (150–300 nm) and 9.3 ± 4.6 for larger aerosols (0.5–2.0 μm). HFNC exhibited a flow‐dependent increase in particulate matter (PM) generation—at 60 LPM, HFNC had a substantial generation of small (55% increase) and large particles (70% increase) compared to 15 LPM. CPAP was associated with lowered small and large particle generation (≈ 10–15% below baseline for both sizes of PM). A patient mask limited particle generation with the NRB, where it was associated with a reduction in small and large particulates (average 40% and 20% lower, respectively). CONCLUSION: Among 3 standard oxygenation procedures, higher flow rates generally were associated with greater production of both small and large aerosols. A patient mask lowered aerosol counts in the NRB only. Protocol development for oxygenation application should consider these factors to increase health care worker safety.