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Endoscopy
Original research
Identification of the source events for aerosol generation during oesophago-gastro-duodenoscopy
  1. Florence K A Gregson1,
  2. Andrew J Shrimpton2,3,
  3. Fergus Hamilton4,
  4. Tim M Cook5,
  5. Jonathan P Reid1,
  6. Anthony E Pickering2,6,
  7. Dimitri J Pournaras7,
  8. Bryan R Bzdek1,
  9. Jules Brown3
  10. the AERATOR group
    1. 1 School of Chemistry, University of Bristol, Bristol, UK
    2. 2 School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
    3. 3 Department of Anaesthesia and Intensive Care Medicine, North Bristol NHS Trust, Bristol, UK
    4. 4 Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
    5. 5 Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals NHS Trust, Bath, and Bristol Medical School, University of Bristol, Bristol, UK
    6. 6 Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol, UK
    7. 7 Department of Upper Gastrointestinal and Bariatric/Metabolic Surgery, North Bristol NHS Trust, Bristol, UK
    1. Correspondence to Dr Jules Brown, Department of Anaesthesia and Intensive Care Medicine, North Bristol NHS Trust, Bristol, UK; jules.brown{at}nbt.nhs.uk

    Abstract

    Objective To determine if oesophago-gastro-duodenoscopy (OGD) generates increased levels of aerosol in conscious patients and identify the source events.

    Design A prospective, environmental aerosol monitoring study, undertaken in an ultraclean environment, on patients undergoing OGD. Sampling was performed 20 cm away from the patient’s mouth using an optical particle sizer. Aerosol levels during OGD were compared with tidal breathing and voluntary coughs within subject.

    Results Patients undergoing bariatric surgical assessment were recruited (mean body mass index 44 and mean age 40 years, n=15). A low background particle concentration in theatres (3 L−1) enabled detection of aerosol generation by tidal breathing (mean particle concentration 118 L−1). Aerosol recording during OGD showed an average particle number concentration of 595 L−1 with a wide range (3–4320 L−1). Bioaerosol-generating events, namely, coughing or burping, were common. Coughing was evoked in 60% of the endoscopies, with a greater peak concentration and a greater total number of sampled particles than the patient’s reference voluntary coughs (11 710 vs 2320 L−1 and 780 vs 191 particles, n=9 and p=0.008). Endoscopies with coughs generated a higher level of aerosol than tidal breathing, whereas those without coughs were not different to the background. Burps also generated increased aerosol concentration, similar to those recorded during voluntary coughs. The insertion and removal of the endoscope were not aerosol generating unless a cough was triggered.

    Conclusion Coughing evoked during OGD is the main source of the increased aerosol levels, and therefore, OGD should be regarded as a procedure with high risk of producing respiratory aerosols. OGD should be conducted with airborne personal protective equipment and appropriate precautions in those patients who are at risk of having COVID-19 or other respiratory pathogens.

    • endoscopy
    • COVID-19
    • endoscopic procedures

    Data availability statement

    Data are available in a public, open access repository. Data underlying the figures and the raw data used in the analysis have been made publicly available in the BioStudies database, https://www.ebi.ac.uk/biostudies/, under accession ID S-BSST670.

    This article is made freely available for personal use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

    https://bmj.com/coronavirus/usage

    https://doi.org/10.1136/gutjnl-2021-324588

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      Data availability statement

      Data are available in a public, open access repository. Data underlying the figures and the raw data used in the analysis have been made publicly available in the BioStudies database, https://www.ebi.ac.uk/biostudies/, under accession ID S-BSST670.

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      Footnotes

      • Twitter @_andyshrimp

      • FKAG and AJS contributed equally.

      • Collaborators AERATOR group: Arnold, D; Brown, J; Bzdek, B; Davidson, A; Dodd, J; Gormley M; Gregson, F; Hamilton, F; Maskell, N; Murray, J; Keller, J; Pickering, A.E; Reid, J; Sheikh, S; and Shrimpton, A.

      • Contributors FKAG and AJS are joint first authors on this article. AJS, JB, DJP and FH collected the data. FKAG, AJS and AEP performed the data analysis. JB, AEP, AJS, FKAG and TMC drafted the manuscript. BRB, JPR and AEP provided technical guidance and advice. All authors read and approved the final manuscript.

      • Funding The AERATOR study was fully funded by an NIHR–UKRI rapid rolling grant (Ref: COV0333). This report presents independent research commissioned by the National Institute for Health Research (NIHR). BRB is supported by the Natural Environment Research Council (NE/P018459/1).

      • Disclaimer The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, NIHR, UKRI or Department of Health.

      • Competing interests None declared.

      • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

      • Provenance and peer review Not commissioned; externally peer reviewed.