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- Title
Generation of Aerosols by Noninvasive Respiratory Support Modalities: A Systematic Review and Meta-Analysis.
- Authors
Zhang, Madeline X.; Lilien, Thijs A.; van Etten-Jamaludin, Faridi S.; Fraenkel, Carl-Johan; Bonn, Daniel; Vlaar, Alexander P. J.; Löndahl, Jakob; Klompas, Michael; Bem, Reinout A.
- Abstract
Key Points: Question: Do high-flow nasal oxygen and noninvasive ventilation qualify as aerosol-generating procedures? Findings: This systematic review of 24 studies and meta-analysis of 5 studies found no evidence that either high-flow nasal oxygen or noninvasive ventilation results in clinically relevant increases in pathogen emission or aerosol production. Meaning: On the basis of the current evidence, high-flow nasal oxygen and noninvasive ventilation appear not to be aerosol-generating procedures and therefore do not merit differential infection prevention and control measures at this time. This systematic review with meta-analysis evaluates current evidence to determine whether high-flow nasal oxygen and noninvasive ventilation are associated with pathogen-laden aerosols and aerosol generation. Importance: Infection control guidelines have historically classified high-flow nasal oxygen and noninvasive ventilation as aerosol-generating procedures that require specialized infection prevention and control measures. Objective: To evaluate the current evidence that high-flow nasal oxygen and noninvasive ventilation are associated with pathogen-laden aerosols and aerosol generation. Data Sources: A systematic search of EMBASE and PubMed/MEDLINE up to March 15, 2023, and CINAHL and ClinicalTrials.gov up to August 1, 2023, was performed. Study Selection: Observational and (quasi-)experimental studies of patients or healthy volunteers supported with high-flow nasal oxygen or noninvasive ventilation were selected. Data Extraction and Synthesis: Three reviewers were involved in independent study screening, assessment of risk of bias, and data extraction. Data from observational studies were pooled using a random-effects model at both sample and patient levels. Sensitivity analyses were performed to assess the influence of model choice. Main Outcomes and Measures: The main outcomes were the detection of pathogens in air samples and the quantity of aerosol particles. Results: Twenty-four studies were included, of which 12 involved measurements in patients and 15 in healthy volunteers. Five observational studies on SARS-CoV-2 detection in a total of 212 air samples during high-flow nasal oxygen in 152 patients with COVID-19 were pooled for meta-analysis. There was no association between high-flow nasal oxygen and pathogen-laden aerosols (odds ratios for positive samples, 0.73 [95% CI, 0.15-3.55] at the sample level and 0.80 [95% CI, 0.14-4.59] at the patient level). Two studies assessed SARS-CoV-2 detection during noninvasive ventilation (84 air samples from 72 patients). There was no association between noninvasive ventilation and pathogen-laden aerosols (odds ratios for positive samples, 0.38 [95% CI, 0.03-4.63] at the sample level and 0.43 [95% CI, 0.01-27.12] at the patient level). None of the studies in healthy volunteers reported clinically relevant increases in aerosol particle production by high-flow nasal oxygen or noninvasive ventilation. Conclusions and Relevance: This systematic review and meta-analysis found no association between high-flow nasal oxygen or noninvasive ventilation and increased airborne pathogen detection or aerosol generation. These findings argue against classifying high-flow nasal oxygen or noninvasive ventilation as aerosol-generating procedures or differentiating infection prevention and control practices for patients receiving these modalities.
- Subjects
AIR microbiology; ONLINE information services; CINAHL database; AEROSOLS; META-analysis; MEDICAL information storage &; retrieval systems; CONFIDENCE intervals; SYSTEMATIC reviews; ARTIFICIAL respiration; INFECTION control; OXYGEN therapy; MEDLINE; SENSITIVITY &; specificity (Statistics); ODDS ratio
- Publication
JAMA Network Open, 2023, Vol 6, Issue 10, pe2337258
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2023.37258