IAMM 2021 Hofmeyr COVID Controversies

Transcrição de áudio Gerado automaticamente

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  Good day to you all around the world.

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  It's my privilege to join today to discuss airway management

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  during the COVID-19 pandemic with a specific eye on special

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  projects and ideas and people's pet peeves about how we

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  can look after practitioners during this very tricky challenge that

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  is before and all of us.

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  My name is Roz Hofmeyr and I am the airway

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  lead at the University of Cape Town's Department of Anesthesia

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  and peri operative Medicine and I've been lied for our

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  covid anesthesia, Airway intubation and retrieval team.

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  You can reach out to me via twitter or email

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  at ross dot Hofmeyr at u c t dot c

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  0.0.0.0 or at ross Hofmeyr.

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  And I'll give you selected references from this presentation at

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  the end of the talk for you to download.

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  So here in South Africa and particularly at the tip

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  of Africa in Cape Town.

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  We were somewhat geographically isolated from the start of the

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  COVID-19 outbreak, which gave us a little bit of time

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  to watch what was going on in the rest of

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  the world to learn from many of you and to

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  prepare our own response.

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  As you can see, we had our first patients around

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  march of 2020, but by the end of March we're

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  beginning to get particularly quite busy sitting down in South

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  Africa, we could really examine what we did know about

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  the disease and about the pandemic and trying to learn

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  from the findings of others.

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  And obviously much of the world's response was based on

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  the earlier work on the early SARS pandemic.

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  What did we know at the time?

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  Well, we were facing respiratory virus which we presume to

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  have contact and droplet spread and which behaves a lot

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  like a SARS.

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  We expected it's behavior like SARS, although we recognize that

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  it was probably more virulent, but a lot less lethal.

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  Now, if you go back and look at the airway,

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  work around SARS, then you'll immediately bump into this paper

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  by train and colleagues, which looked at the so called

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  area sold generating procedures and the increased risk of transmission

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  to health care practitioners.

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  We recognize from this work that there was an odds

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  ratio about 6.6 for these practitioners involved in skills such

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  as intubation to become ill with the respiratory illness.

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  And so out of this grew this concept of being

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  very cautious around aerosol generating procedures such as intubation, mask

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  ventilation. But this actually grew to include quite a lot

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  of other procedures as well.

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  And there was a lot of uncertainty and a lot

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  of uncertainty that led to a lot of fear.

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  This dichotomy in the requirements for different kinds of PP

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  led to principles whereby if one was working with covid

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  patients where you weren't doing so called a GPS, then

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  you could use one set of PPE simple droplet and

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  contact precautions.

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  But if you were going to intubate or manage an

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  airway or do CPR or fiddle with the ventilator, then

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  you would need to put on so called a g

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  p p p E or a high level of PPE.

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  Now one can really say that most of us at

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  this stage, we're working on educated best guesses based on

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  the available science with a lean towards caution.

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  In fact, here is one of our congress chairs Eleanor

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  Sullivan presenting in february last year in Cape Town, I'm

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  sorry, in Pretoria, in South Africa and giving her recommendations

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  on what we were thinking at the time would be

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  effective for covid airway management.

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  And many of these concepts have in fact stood the

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  test of time because they were based on reasonably good

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  science, but some of them have not.

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  So let's delve a little bit deeper into that.

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  Of course, around this time, worldwide hordes of guidelines are

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  being produced just about everybody had their good ideas to

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  share. And there was a lot of collaboration that was

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  going on and we were able to take much of

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  this material modified and adapted to suit the local needs.

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  And for instance, we produced these socks or South African

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  and the society guidelines, which I was the first author

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  and of which we are still using.

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  Although with some modifications, we presumed at the time that

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  as anything else, we would spend a lot of our

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  time working in hot and not hot zones.

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  We would be able to go into infected areas or

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  going to an operating theater to a covid anesthetic and

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  we would be able to have safe zones outside which

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  we could have personnel who would be safer from infection.

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  And we based a lot of our thinking around this.

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  We produce a lot of training material.

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  We produce a series of videos which is used across

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  the country, in fact elsewhere on the continent to help

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  prepare people rapidly for the coming pandemic.

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  We also use our experience and institute simulation to perfect

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  these protocols to iterative.

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  We work on improving them to train a lot of

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  our staff and to dispel fear around the virus itself.

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  Another very useful use for us of in situ simulation

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  was to use it in the clinical areas that were

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  being set up and dedicated to Covid, which allowed us

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  to do systems testing in those areas and also test

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  the ad hoc teams that would form and the multidisciplinary

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  teams that would form as we anticipated, bringing in a

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  lot of clinical staff from different disciplines.

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  So in fact, by the time we started managing our

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  first covid patients with severe covid pneumonia.

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  By late March of 2020 we have a specialized anesthesia

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  and retrieval team.

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  And we developed a lot of hospital wide expertise across

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  disciplines. And this really, really helped when we became very

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  busy. One of the challenges that we experienced quite early

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  in South Africa was a local shortage, which reflected the

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  global shortage of PPE.

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  And this led us to using some things like reusable

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  goggles, reasonable respirators, filters, which you could use for a

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  longer period of time, Unsterile surgical guns, which we could

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  wash and reuse.

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  And perhaps this early adoption of rigorous infection control practices,

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  even though we were using multi use PPE might have

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  been a strength which assisted us other strengths, which we

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  can speak to was the fact that this iterative training

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  and learning across disciplines broke down silos.

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  It gave us a broad clinical experience that allowed us

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  to form ad hoc teams very rapidly.

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  And the integration and increased acceptance of simulation was a

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  very, very powerful tool from us.

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  So within our own institution, this is my hospital where

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  I'm standing currently.

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  Critics here in Cape Town, we found our experience is

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  very similar to that experienced around the rest of the

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  world. We found patients with severe, profound hypoxia, often despite

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  being on high flow nasal oxygenation and having Pronin etcetera.

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  In fact, our hospital was quite early to adopt the

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  use of hypno and self pruning.

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  And so many of these patients who we intubated our

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  primary cause for intubation was respiratory failure, having already tried

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  and failed high frequency nasal oxygenation.

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  So by the time our intubation team was called to

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  many of these patients, they were in extremist with very,

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  very severe disease requiring invasive ventilation in the intensive care

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  unit. Of course, as others have found, we had very,

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  very profound the saturation these patients, despite what I believe

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  to be a proficient and effective airway team bearing in

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  mind that our airway team performing these interventions retrievals was

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  all senior anesthesia trainees and specialists working on very tight

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  protocols using ubiquitous video are endoscopy, which meant that we

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  had very few difficult or failed airways across that entire

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  group. What we did experience a lot of, as others

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  have commented, is severe hypoglycemia as well as a lot

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  of Perry induction hypertension and in fact, a fair number

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  of cardiac arrest.

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  About 1% of patients suffering a perry induction uh cardiac

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  arrest. This led to a lot of patients requiring anna

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  tropic support going forward into ICU.

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  Now, if these experiences sound familiar to you, these challenges

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  sound familiar.

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  Hopefully that sets the tone for the rest of the

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  talk. But if you'd like to learn more about how

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  we managed our covid pandemic and our experience here at

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  risk in Cape Town.

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  These to open access papers in the South African Medical

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  Journal are available to you or just drop me a

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  line and I'll happily forward them to you.

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  Now they say necessity is the mother of invention.

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  And certainly there was a lot of well meaning invention

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  around how to protect practitioners, particularly in South Africa.

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  The main reasons we experience this was the dwindling PPE

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  supplies and the fear around the PPE stocks running out

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  and practitioners being exposed.

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  A very, very common uh, innovation that we saw which

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  emerged from various industries and a lot of different groups

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  trying to be useful was these barrier devices, intubation boxes,

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  uh, intubation screens and so forth.

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  And, and a lot of industries support going into developing

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  these things and trying to rapidly bring them into, into

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  public practice.

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  We had some concerns about this and a group of

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  many of the people who are on this conference and

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  speaking here, we got together and did a fairly early

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  review of looking at the evidence behind these different devices.

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  And we're a little bit disappointed to say that we

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  really struggled to find a good evidence for the use

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  of barrier devices, although there was a lot of heterogeneity

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  between the different types and the methods of the studies.

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  And we really called for better quality research and better

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  quality evidence.

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  I'm glad to say that a lot of that evidence

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  has been forthcoming.

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  The cry for more robust research has been met with

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  good quality work, such as this paper by Biglia Tell,

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  who showed with intubation boxes longer incubation times lower, first

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  past success and concerning the damage to PPE of practitioners

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  using the boxes.

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  Other studies such as that of Simpson, looked at the

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  very eloquently at the use of these boxes and the

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  concern about secondary aerosolization, whereby gas and aerosols that are

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  trapped around the patient inside the box might actually increase

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  exposure of the practitioners who are involved.

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  Although an interesting thing which has emerged and this has

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  come from several papers and reflected here in this work,

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  is the use of high volume extractions and not just

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  normal suction, but high volume extraction with these boxes, which

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  may well rapidly decrease the aerosol load, and that is

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  potentially a very good place for us to look for

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  winds in this field in the future.

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  More recently found, and colleagues have published in the Canadian

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  Journal, another simulation study, which again, particularly difficult airway models

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  showed increased difficult intubation, more attempts, more optimization maneuvers required

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  and again, breaches of PPE, which again is concerning so

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  very well meaning idea in creating new barriers.

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  Not so far been shown to be particularly valuable and

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  may in fact be a concerning risk to our practitioners.

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  Another area of uh innovation which we saw worldwide in

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  which we did some work on here in South Africa

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  as well.

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  It was a conversion of non medical equipment into PPE

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  and ventilation devices.

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  So these uh, to my enthusiastic registrars here wearing full

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  face snorkeling masks which have been modified with three D

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  printed connectors to allow the application of standard uh respiratory

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  filters so we can add a viral or bacteriological filter.

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  And various authors have proposed the use of these devices

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  for droplet and uh aerosol protection, particularly using high efficiency

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  filters to give very good respiratory protection or in fact

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  converting them for the useful noninvasive ventilation.

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  Particularly interesting suggestion.

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  Now there has been some good work, particularly in the

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  laboratory looking at these options.

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  And here is a very nice paper from Seligman and

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  colleagues who used a full face snorkel masks, versace and

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  FFB three mask advisor and showed that there was a

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  lot less deposition uh fluorescent particles when performing basic skills

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  using these two comparative devices.

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  So perhaps there is some room to use these devices

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  for effective protection.

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  Of course, there a lot of questions and some of

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  our own work has gone around this which is currently

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  under review, looking at whether or not they are clinically

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  usable, whether they are likely to fog.

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  There's some work around the issues that might make communication

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  quite difficult.

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  But certainly this is an area that we can examine

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  further. But the jury is to a certain extent.

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  Still out now, some of the most fundamental work has

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  been done looking not at laboratory but at real world

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  outcomes of practitioners who involved in caring for covid patients

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  and looking at the real world transmission of us and

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  colleagues who are doing these skills.

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  One of the largest studies to which many of us

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  contributed data is the intubate covid study, which showed an

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  overall incidence of covid 19 diagnosis or symptomatic isolation of

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  about 10 to 11% for healthcare workers doing tracheal intubation.

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  So, despite many of these health care workers, if you

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  go and have a look at the study using personal

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  protective equipment, there was still a significant and a concerning

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  risk of transmission.

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  Of course, it's very difficult to peel apart this transmission

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  that might be in the workplace.

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  Might be during intubation from general risk being in the

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  hospital environment or from community spread again.

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  Many of the uh faculty involved with this meeting and

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  really friends of items were involved in writing this paper.

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  Looking at controversies and airway management which showed some interesting

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  trends around the use of various levels of PP and

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  also high frequency nasal oxygenation.

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  A great challenge with PPE is actually just defining what

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  we mean because even a simple things such as an

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  apron Oregon can have very different meanings in different places

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  and we might be made of very different materials and

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  the training in the donning and doffing might be different.

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  And so it's very tricky to compare these things unless

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  you can standardise I.

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  P. C.

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  Protocols and in fact your infection prevention control protocols need

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  to be ideally standardized.

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  I need to be very good because PP alone is

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  not enough to reduce transmission.

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  You need a very good protocol you can see with

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  increasing degrees or increasing levels of PPE.

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  There is a deep uh increasing levels causes of decreasing

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  transmission. However, our own team was somewhat of an outlier

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  and that we had no transmission at all during our

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  first wave.

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  And that's probably despite the fact that we only use

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  about level two PPE got to do with the fact

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  that we had very very strict I.

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  P. C.

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  Protocols and used a hot not hot kind of setting

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  that we weren't in these environments for continuous basis.

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  So this leads to the question about are we creating

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  unintended consequences?

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  Are we focusing too much on the procedures and not

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  the principles protecting us against transmission?

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  Uh And we're attributing too much attention to the gps

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  and not enough to being in the clinical environment in

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  the so called low risk settings which actually people spend

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  much more time and are much more common.

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  So in fact perhaps we are getting less transmission because

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  although we are in a high risk setting we are

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  low risk specialty in uh in anesthesia and critical care

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  because we are so much more aware and often much

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  more well protected in this great work by cooking colleagues

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  shows that were good enough at looking after ourselves.

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  But are we being diligent enough about looking after colleagues

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  in the non critical care setting?

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  In I.

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  C. U.

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  With all the patients intubated breathing through filters?

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  Well that's really a very safe situation.

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  So there is increasing evidence of aerosol spread which is

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  both in the community setting and in the medical setting.

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  We're probably quite familiar with the two examples of restaurants

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  and diners in Korea and in china where there's pretty

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  good evidence that different people sitting in the restaurant setting

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  contracted covid through aerosolized rather than drop it spread.

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  And then there's increasing good quality medical research into this

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  new field of medical error biology, such as this work

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  of Wilson.

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  It'll which shows that even people who are breathing normally

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  at rest or particularly people who are exercising or coughing

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  or speaking or shouting actually generate more particulates and more

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  aerosols than a common medical interventions such as high frequency

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  nasal oxygenation or noninvasive positive pressure ventilation.

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  Again, work by Brown recently published an anesthesia has shown

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  that particularly with good quality intubation and excavation, particularly muscle

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  relaxation. Actually there is a lot less production of aerosols

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  than would happen with a patient who is coughing or

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  breathing rapidly.

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  So you're probably more at risk while taking consent for

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  intubation. Then you are while performing the intubation itself.

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  And this has led to a very nice commentary in

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  the Lancet respiratory medicine earlier this month saying that perhaps

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  we really need to take this concept of aerosol generating

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  procedures out of our lexicon and just talk about the

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  overall risk of aerosol spread of this disease.

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  And we need to protect patients and practitioners thinking about

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  the patient, risk the duration of the exposure, the health

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  practitioners own, risk the proximity, and then the environment that

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  we're in and by reducing our environmental risks of contamination,

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  by improving things like ventilation, by separating people and ultimately,

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  by eliminating the pathogen, we can do a lot more

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  than just adding personal protective equipment.

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  So in conclusion, perhaps to leave you with some ideas,

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  I think that we need to today presume aerosol spread

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  of Covid 19 or SARS COv two.

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  We need to have equal protection for all of our

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  practitioners who working in clinical areas.

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  And we need to very carefully test the ideas and

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  the assumptions that have led us to our ideas when

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  we're trying to intubate, trying to introduce new concept.

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  Ladies and gentlemen, thank you.

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  I hope that I have not taken too much of

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  your time.

• 16:17 - 16:20

  I'll be available to chat off line and take questions.

• 16:20 - 16:24

  Otherwise you're welcome to download and examine the selected references

• 16:24 - 16:25

  from this talk here.

• 16:26 - 16:28

  And I look forward to chatting with you further.