Aerosol-generating procedures

3.3

Many respiratory physiotherapy interventions are potentially aerosol-generating procedures. While there are insufficient investigations confirming the aerosol generating potential of various physiotherapy interventions, the combination with cough for airway clearance makes all techniques potentially aerosol-generating procedures.

These include:

· cough-generating procedures (e.g. cough during treatment or huff)

· positioning or gravity-assisted drainage techniques and manual techniques (e.g., expiratory vibrations, percussion and manual assisted cough) that may trigger a cough and sputum expectoration

· use of positive pressure breathing devices (e.g. inspiratory positive pressure breathing), mechanical insufflation-exsufflation devices, intra/extra pulmonary high-frequency oscillation devices (e.g. The Vest, MetaNeb, Percussionaire)

· PEP and oscillating PEP devices

· Bubble PEP

· Nasopharyngeal or oropharyngeal suctioning

· Manual hyperinflation

· Open suction

· Saline instillation via an open-circuit endotracheal tube

· Inspiratory muscle training, particularly if used with patients who are ventilated and disconnection from a breathing circuit is required

· Sputum inductions

· Any mobilisation or therapy that may result in coughing and expectoration of mucus

Therefore, there is a risk of creating an airborne transmission of COVID-19 during treatments. Physiotherapists should weigh up the risk versus benefit to completing these interventions and use airborne precautions.

3.4

Where aerosol-generating procedures are indicated and considered essential, they should be undertaken in a negative-pressure room, if available, or in a single room with the door closed. Only the minimum number of required staff should be present and they must all wear PPE, as described. Entry and exit from the room should be minimised during the procedure.

This may not be able to be maintained when cohorting is required because of the volume of patients presenting with COVID-19.

3.5

Bubble PEP is not recommended for patients with COVID-19 because of uncertainty around the potential for aerosolisation, which is similar to the caution the WHO places on bubble CPAP.

3.6

There is no evidence for using incentive spirometry in patients with COVID-19.

3.7

Avoid the use of mechanical insufflation/exsufflation, non-invasive ventilation, inspiratory positive pressure breathing devices or high-flow nasal oxygen devices.

However, if clinically indicated and alternative options have been ineffective, consult with both senior medical staff and Infection Prevention and Monitoring Services within local facilities prior to its use.

If used, ensure that machines can be decontaminated after use and protect machines with viral filters over machine and patient ends of circuits.

· Use disposable circuits for these devices

· Maintain a log for devices that includes patient details for tracking and infection

· Monitoring (if required)

· Use airborne precautions’

3.8

Where respiratory equipment is used, whenever possible, use single-patient-use disposable options (e.g., single-patient-use PEP devices).

Re-usable respiratory equipment should be avoided, where possible.

3.9

Physiotherapists should not implement humidification, non-invasive ventilation or other aerosol-generating procedures without consultation and agreement with a senior doctor (e.g, medical consultant).

Sputum inductions

3.10

Sputum inductions should not be performed.

Requests for sputum samples

3.11

In the first instance, ascertain whether the patient is productive of sputum and able to clear sputum independently. If so, physiotherapy is not required for a sputum sample. If physiotherapy interventions are required to facilitate a sputum sample, full airborne, full PPE should be worn. The handling of sputum samples should adhere to local policies. Generally, once a sputum sample has been obtained the following points should be followed:

· All sputum specimens and request forms should be marked with a biohazard label.