key: cord-0778895-w1nzgclx authors: Dalli, J.; O'Keeffe, D. A.; Khan, F.; Traynor, O.; Cahill, R. A. title: Powered Air Purifying Respirators (PAPR) for the protection of surgeons during operative tasks: a user perspective assessment date: 2020-07-16 journal: Br J Surg DOI: 10.1002/bjs.11782 sha: 96dc28d642f3f50fac5ac5bf7034aca5b85efd87 doc_id: 778895 cord_uid: w1nzgclx nan The unfolding COVID-19 pandemic has challenged surgical care where aerosol-generating operations may expose the surgical team 1,2,3 . Optimization of theatre airflow management and the application of smoke evacuation devices have been recommended and some personal protective equipment may remain for the foreseeable future 1,2,3 . WHO guidelines advise well-fitting respirators (for example FFP2/3 or N95 masks) for surgical teams as the minimum where there is exposure risk. These disposable masks are becoming scarce and may not offer the required protection especially when poorly fitted. Powered Air Purifying Respirators (PAPR) are another type of respiratory protection that are validated to offer higher respiratory protection by regulatory bodies (2⋅5-100x Airway Protection Factor versus N95 masks). These respirators feature a waist-mounted battery-powered pump that blows filtered air into a hood and are reusable. These devices are widely used in other industries but haven't been formally assessed for operating room teams. As part of a validation exercise, a frontline clinical user perspective assessment was performed of donated PAPR under operating conditions in high-fidelity simulation environments. Scott Tornado (3 M) PAPR with both half (FH1) and full (FH2) hoods was tested by 46 clinicians (36 surgeons, six anaesthetists and four nurses) without prior PAPR experience in elective and emergency general surgery (open and laparoscopy), plastics and reconstructive surgery and head and neck/dental surgery simulations with subjective and objective evaluation. Initially, surgeons in PAPR carried out both laparoscopic and open tasks individually and in pairs including simulated minimal access appendicectomy and porcine laparotomy (involving splenectomy, cholecystectomy and bowel resection/anastomosis) over 90-120 mins. Thereafter, complete operative SIM-MAN simulation was performed with four full specialty teams all wearing PAPR, specifically laparoscopic appendectomies (two teams), tracheostomy and cleft palate repair with dental extraction (Fig. 1) . Subjective confidence, comfort and communications scores were collected at fixed intervals using established, adopted and designed methodology (Appendix S1). Collaborative team working was also assessed objectively, including an unexpected challenge during scenarios by planned telephone interruption. Social distancing was observed. PAPR was well accepted regardless of hood type and all tasks were completed within the allocated time (Table 1) . There was no temporal deterioration of scores. Confidence in PAPR use Borg rating of perceived exertion 6 (no exertion at all) to 20 (maximal exertion) Nurses 1⋅80 ± 0⋅79 * Statistically significant results (P < 0⋅05). Statistically significant P value (Mann-Whitney U test) for a surgeons versus nurses with respect to thermal sensation score and for b surgeons versus anaesthesiologists for perception of breathing. significantly improved after assessment (postop median score of 4/5 versus 3 pre-test, P = 0⋅002, Sign Test). FH1 hoods scored best for comfort and communication. Surgeons reported less heat and breathing impact than anaesthesiologists and nurses. Qualitative comments were generally positive with users feeling 'protected' and 'safe'. Pumps alarmed when gowns obstructed the inflow and the fixed length tubing impacted shorter individuals' gowning and teams spatially with respect to sterility but these were manageable. Conventional stethoscopes and loupes could not be used. Alongside ongoing emergency and time-critical surgery, surgical services now need resumption 5 including address of the 'third wave' of procedure backlog. PAPR may be fit for surgical settings if needed with local approval and adequate training. Safe management of surgical smoke in the age of COVID-19 Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services Global guidance for surgical care during the COVID-19 pandemic Elective surgery after the pandemic: waves beyond the horizon Thanks to Medtronic for making PAPR equipment available free of charge to several hospitals due to the outbreak of COVID-19. None of the authors have conflicts of interest directly related to this study. Corp, consultancy payments from Distalmotion and Touch Surgery and holds research funding from Intuitive Surgery and with IBM. Additional supporting information can be found online in the Supporting Information section at the end of the article.