The Critical Role of PPE in Airway Management
Intubation is a procedure that can create infectious aerosols, putting healthcare workers at a high risk of exposure to airborne pathogens. Proper use of personal protective equipment (PPE) creates a physical barrier, protecting the user from splashes, sprays, and infectious droplets or aerosols. Given that intubation is an aerosol-generating procedure (AGP), a higher level of protection is required compared to routine patient care, especially during pandemics or when caring for patients with known or suspected respiratory infections. Understanding the components of this vital equipment and the correct protocols for its use is fundamental to maintaining a safe clinical environment.
Essential Components of PPE for Intubation
To provide comprehensive protection, the PPE ensemble for intubation is multi-layered, addressing potential exposure points for the head, face, body, and hands.
Respiratory Protection
- N95 Respirator: An N95 is a tight-fitting, disposable filtering facepiece that filters at least 95% of airborne particles. It is the minimum standard for respiratory protection during AGPs. Healthcare workers must undergo fit-testing to ensure an adequate seal, as improper fit compromises protection.
- Powered Air-Purifying Respirator (PAPR): A PAPR is a battery-operated system that uses a blower to pass contaminated air through a HEPA filter and into a loose-fitting hood or helmet. PAPRs offer a higher level of protection than N95s and are recommended for the highest-risk scenarios or when an N95 cannot be worn or properly fit-tested.
Eye and Face Protection
- Face Shield: A full-face shield provides a barrier against splashes and sprays to the face, protecting the eyes, nose, and mouth. It is typically worn over an N95 mask to extend the life of the respirator by preventing surface contamination.
- Goggles: Goggles are an alternative to face shields, providing a tighter seal around the eyes. They must be worn in conjunction with a mask or respirator to protect the rest of the face.
Body Protection
- Gown: A fluid-resistant or impermeable gown is essential to protect skin and clothing from contamination. It should cover the torso from the neck to the knees and the arms to the end of the wrists. For higher-risk situations, coveralls may be used for more complete coverage.
- Head Cover and Shoe Covers: In high-risk situations, disposable caps and shoe covers are often included to prevent contamination of hair and footwear.
Hand Protection
- Gloves: Non-sterile gloves should be worn to protect hands from contact with blood and body fluids. For intubation, double-gloving is a common practice to minimize the risk of contamination, especially when handling contaminated equipment.
Comparison of Standard vs. High-Risk Intubation PPE
Selecting the appropriate PPE requires an assessment of the patient's infectious status and the procedure being performed. The table below compares the general recommendations for standard vs. high-risk intubation scenarios.
| PPE Item | Standard Intubation (Non-Infectious) | High-Risk (Suspected/Confirmed Infectious AGP) |
|---|---|---|
| Respirator | Surgical mask | N95 or higher-level (PAPR) |
| Eye Protection | Goggles or Face Shield | Face Shield (required) |
| Gown | Isolation Gown | Impermeable Gown or Coveralls |
| Gloves | Single Gloves | Double Gloves (often recommended) |
| Head Cover | Optional | Required |
| Shoe Cover | Optional | Recommended |
The Critical Donning and Doffing Sequence
The sequence of putting on (donning) and taking off (doffing) PPE is as critical as the equipment itself. The highest risk of self-contamination occurs during the doffing process. Healthcare workers should always follow established protocols, often with a trained observer, to ensure no step is missed.
Donning (Putting On)
- Perform Hand Hygiene.
- Put on Gown. Tie all ties, ensuring full coverage.
- Put on Respirator. For an N95, perform a user seal check. For a PAPR, put on the hood or helmet.
- Put on Eye Protection. Place goggles or face shield over the respirator.
- Put on Gloves. Ensure gloves extend over the cuffs of the gown.
Doffing (Taking Off)
- Remove Gloves. Peel off the outer pair of gloves and discard.
- Remove Gown. Unfasten the ties, pulling the gown away from the body while turning it inside out. Discard it immediately.
- Perform Hand Hygiene. Use hand sanitizer or wash hands.
- Remove Eye Protection. Remove goggles or face shield by the head straps or earpieces, avoiding touching the front.
- Remove Respirator. Remove the N95 by grasping the bottom and then the top straps. For a PAPR, remove the hood.
- Perform Final Hand Hygiene.
For a detailed, step-by-step visual guide on donning and doffing, consult the CDC Guidelines on Putting On and Removing PPE.
Consequences of Improper PPE Use
Negligence in the use of PPE can have severe consequences for both healthcare staff and patients. Improperly worn or removed PPE can lead to cross-contamination, increasing the risk of healthcare-associated infections. For the healthcare provider, this can mean direct exposure to dangerous pathogens transmitted through aerosols and splashes. For the patient, contamination can lead to surgical site infections, prolonged hospital stays, and increased morbidity. Consistent adherence to established protocols is a non-negotiable aspect of safe airway management.
Conclusion
Knowing what PPE is needed for intubation is a cornerstone of infection control in modern medicine. The proper assembly and use of respiratory protection (N95 or PAPR), eye protection, gowns, and gloves are non-negotiable steps to ensure the safety of both healthcare providers and patients. By following established donning and doffing procedures and understanding the necessary layers of protection for different risk levels, medical teams can mitigate risks and perform critical procedures like intubation with confidence and safety.
