Healthcare Worker PPE, March 2 - 3, 2010

National Personal Protective
Technology Laboratory

HEALTHCARE WORKER UNIVERSAL
PRECAUTIONS INTERFACES AND
ASSOCIATED ISSUES

Raymond Roberge, MD, MPH
Research Medical Officer, NIOSH/NPPTL

♦

March 2-3, 2010

PROTECTIVE

CLOTHING
REQUIRED

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UNIVERSAL PRECAUTIONS

Universal Precautions refers to the practice, in
medicine, of avoiding contact with patients' bodily
fluids, by means of wearing of nonporous PPE such as
gloves, gowns, respirators, surgical masks, goggles,
and face shields. The assumption is that all bodily fluids
are potentially infectious and must be so treated.

Standard Precautions apply to 1) blood; 2) all body
fluids, secretions, and excretions, except sweat,
regardless of whether or not they contain visible blood;
3) non-intact skin; and 4) mucous membranes.

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EYEMERGING" INFECTIOUS DISEASES

Under Occupational Health and Safety Act (OHSA)
Standards 29CFR "masks in combination with eye
protection devices, such as goggles, glasses with
side shields or chin length face shields shall be worn
whenever splashes, spray, splatters or droplets of
blood or other infectious materials may be generated
and eye, nose or mouth contamination can
reasonably be anticipated."

No definitive study to address ophthalmic exposure
when the aforementioned mechanisms are absent
but risk is considered minimal (Buckland and Tyrrell,
1964)

Affinity of ophthalmic receptors for various viruses
may be important limiting factor for some pathogens
(e.g., Avian influenza) N

Nasolacrimal duct function is important for
infectious agents w/o significant binding to
ophthalmic receptors

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HOW IMPORTANT IS FACIAL PROTECTION

DURING SURGERY?

50% of caesarean sections and 32% of
vaginal deliveries associated with
measurable contamination of the face
shield surface that was not detected by the
physician (Kouri and Ernest, 1993)

Polycarb glasses worn by surgical team
members were contaminated in 62% of
orthopedic cases (Giachino etal, 1988)

Face shield contamination was
documented in 33% of facial
dermatological surgical procedures (Birnie
etal, 2007)

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HEALTHCARE WORKER EYE PROTECTION

COMPLIANCE/CONCERNS

• 32% wore regular spectacles during surgery
and 24% wore no eye covering of any kind
(Akdumanetal, 1999)

10% of emergency department and ICU staff
reported never wearing eye protection (Bryce et

• Reasons cited for lack of wear (Lombardi etal,
2009; Greenland etal, 2007; Hutcheon, 2004):

-lack of comfort/fit

-fogging

-scratching of eyewear

-interference with medical procedures (e.g.,

fibreoptic intubation, operative loops, etc.)

-claustrophobic sensations \

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HEALTHCARE WORKER EYE PROTECTION

• Goggles, glasses, face shields, visors

i i EmHf T /

mm Hp^ *U^^^| TfM \ % -T

Ml Mi

(courlaa/ Jk'il)

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EYE PROTECTION/RESPIRATORY PROTECTION

INTERFACES

r

With permission - Canadiai
J ournal of Anesthesiology

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SURGICAL GLOVES

The most used HCWPPE

Helps prevent transmission of infectious
agents

Innovative uses:

-increased grip when performing some

procedures (e.g., shoulder reduction),
-can be used as a tourniquet
-can be used as an ice bag
-can be used to make pediatric

playthings (Mr. Fingerhead)

ourtesy of Dermatology
OnlineJ ournal

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SURGICAL GLOVES - ISSUES

Alter the sense of touch.

Decrease agility with some delicate procedures.

Size issues:

-gloves that are too large for the individual allow finger

slippage leading to decreased dexterity

-gloves that are too small cause discomfort (decreased blood

flow to fingertips; pulling on hand and digit hair) and constrain

finger and hand movements

Become entangled in some instruments

Friction from gloves against the skin can make some procedures
more difficult (e.g., inserting an IV)

Allergy concerns (latex)

Overuse can lead to decreased hand washing

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GLOVE/SLEEVE INTERFACE

"Roll Down" - slippage resulting from low
frictional resistance between the glove inner
surface and the gown sleeve increases risk of
body fluid contamination. w

"Channeling" - as a result of the glove being
pulled over the sleeve, the sleeve is bunched
up under the glove and forms channels along
the wearer's wrist that may allow body fluids
running down the outside of the sleeve to
gain access to the interior of the glove.

Taping may not be effective because the
adhesives are subject to attack by water and
body fluids.

ZamorctfJ . X E. et al. CMAj 2006;175:249-254
Courtesy of CMAJ

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POWERED AIR-PURIFYING RESPIRATOR

INTERFACES

Visual interface- use of other concurrent eye
protection

Equipment interface- use of stethescope,
ophthalmoscope, fibreoptic bronchoscope, etc

• Dermal interface - use of shrouds

With permission - Canadian
J ournal of Anesthesiology

Cuurlcsy uf iluUai d

Zamora, J . E . et al. C MAJ
2006;175:249-254 Courtesy of C MAJ

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FFR PHYSIOLOGICAL
INTERFACES

• Phase I - N95 FFR and N95 FFR/EV vs Controls (no FFR) treadmill
exercising at 1.7mph and 2.5 mph x 1 hr:

• No significant differences in HT, V T , \A, Sa0 2 ,tcPCO
controls versus FFR or FFR/EV at either work rate x one
hour.

• Slight increase (not statistically significant) in V T (range, 38
mL - 148 mL) with respirator use

No significant difference in mean mixed
inhalation/exhalation V D resB CO, (2.86%, 2.92%[p=0.47]) and

hour

• tcPC02 increases (non-significant) were: 0.54/1.26 mm Hg at
1.7/2.5 mph, respectively, for N95 FFR/EV, 1.22 mm Hg for
N95 FFR at 2.5 mph and -.72 mm Hg at 1.7 mph for N95 FFR
(2 subjects > 50 mm Hg)

• No difference in comfort & exertion scores, or moisture
retention

• Roberge RJ , Coca A, Williams WJ , Powell J B, Palmiero AJ . (2010) Physiological impact ofN95 filtering facepiece
respirator ("N95 Masks") use on healthcare workers. Respiratory Care (in press)

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FFR/SURGICAL MASK PHYSIOLOGICAL

INTERFACES

Phase 2 - N95 FFR and N95 FFR/EV vs N95 FFR/SM and N95
FFR/EV/EM treadmill exercising at 1.7mph and 2.5 mph x 1 hr:

No significant differences for N95 FFR/SM and N95 FFR/EV/SM
compared to standard models, for HR,f B , V T , V E , Sa0 2 xone
hour.

Compared with controls, significant decrease in V D resp oxygen
levels with N95 FFR/SM at 1.7 mph (p=0.03) and for N95
FFR/EV/SM at 2.5 mph (p=0.003).

Two subjects had elevated tcPC02 levels (48,60)

No significant differences in comfort & exertion scores, or
moisture retention

Roberge RJ , Coca A, Williams WJ , Palmiero AJ , Powell J B (2010) Surgical mask placement over N95
filtering facepiece respirators: physiological effects on healthcare workers. Respirology (in press)

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EAPR PHYSIOLOGICAL INTERFACES

Phase 3 - elastomeric half facepiece air-purifying
respirator vs control (no respirator) treadmill
exercising at 1.7mph and 2.5 mph x 1 hr:

No significant differences in HR, Sa0 2 , and tcPC0 2 x
one hour compared with controls

Significantly lower f B associated with elastomeric
respirators at both work rates (p=0.02, p=0.03,
respectively)

Significant decrease in V T at 1.7 mph compared with
controls (p=0.009)

Half of subjects at each work rate had elevated tcPCO ;
levels (*45 mm Hg) at the one hour

No significant differences in comfort & exertion
scores, and moisture retention.

Roberge RJ , Coca A, Williams WJ , Powell J B, Palmiero AJ . (2010) Reusable
elastomeric air-purifying respirators: physiological impact on healthcare wc
American J ournal of Infection Control (in press)

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FFR/SURGICAL MASK INTERFACE AND
BREATHING RESISTANCE

Human surrogate : breathing mannequin/headform (Smartman,
ILC Dover, Frederic a, DE) attached to a Dynamic Breathing
Machine (Warwick Technology, Ltd., Warwick, UK) that
delivered sinusoidal breathing patterns at 25 L/min and 40
L/min.

• Room particle counts: 16,000 - 30,000 m 3 by aTSI Particle

[crSTiT2rf?i i

Respirators : N 10 SH -certified N95FFRS (3 replicates x 3 models;
different manufacturers) were individually heat-glued to the
mannequin and Protection Factors* (•100 @ 25 L/min)
quantified by TSI Portacount Plus® particle optical density
measurement.

Breathinq resistance: Inhalation and exhalation breathinq

resistance was measured with an m-lm
Resistance Pressure Transducer Model DP45-24 (Validyne
Engineering Corp, Northridge, CA) for 774 inhalations and 774
total exhalations.

Surgical mask overlay : a non-splash resistant, Type II surgical
mask model (single manufacturer) was applied over the
respirator and pressure measurements repeated and
compared.

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SURGICAL MASK-N95FFR COMBINATION:
BREATHING RESISTANCE RESULTS SUMMARY

Increases in Breathing Resistance

N95FFR MODEL

% inhalation resistance
increase© 25 L/min

% inhalation resistance
increase @ 40 L/min

% exhalation resistance
increase© 25 L/min

% exhalation resistance
increase© 40L/min

A

10.09

12.61

12.30

13.22

B

7.61

8.99

8.56

9.58

C

4.60

6.03

5.79

3.44

Mean

6.99

8.70

8.43

9.48

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RESPIRATOR MICROENVIRONMENT

INTERFACE

• OS HA workplace ambient air standard (respirator not
factored into determination)

- C0 2 <0.5%

- 2 <L9.5% is considered deficient

Mean Respirator Deadspace Gas Centrations After Treadmill Exercise X 1 hr

espirator

N95 FFR/EV/S

ixed inhalati

halation O
oncentrati ~

16-63°/

lixed inhalatio

exhalation CO :
concentration

[Z¥A

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MOISTURE INTERFACE -AMBIENT HUMIDITY,
SWEAT AND EXHALED MOISTURE

• Test Procedure - Automated Breathing and Metabolic Simulator,
and attached breathing mannequin with affixed N95 FFR, N95
FFR/EV, and SN95 FFR (9 models, 45 respirators), programmed at
100% humidity, 342 C exhaled air, 40 LPM breathing volume X four
hours. Controls were the first five minutes of ABMS breathing.
Ambient temp. 22.3 C, RH 40 - 60%.

• Outcome measures: inhalation resistance, exhalation resistance,

FFR moisture retention

i

• Results
- mean inhalation resistance increase from -14.11 mm to -14.54

mm H 2 pressure (increase of -0.43 mm)
-mean exhalation resistance increase from 7.09 to 7.32 mm H 2
pressure (increase of 0.23 mm)

-mean moisture retention after 4 hours was 0.26 ml (-0.02% of total
expired water vapor)

-a significantly lower exhalation resistance was noted for N95 FFR
compared with SN95 FFR after four hours {p=O.O0i7); otherwise, no
significant differences were noted between FFR classes

Roberge RJ , Bayer A, Powell J B, Coca A, Roberge MR, Benson SM: Effect of exhaled moisture on breathing
resistance of filtering facepiece respirators. Ann Occup Hyg (under review)

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Disclaimer:

The findings and conclusions in this presentation have not been
formally disseminated by the National Institute for Occupational
Safety and Health and should not be construed to represent any
agency determination or policy.

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