Could HCWs breathe easier with new respirators?
Project BREATHE looks for respirator innovations
If you could give health care workers the ideal respirator, what would it look like? For the first time, an interagency task force is considering that question in a project they hope will result in a more effective, less cumbersome respirator perhaps one that doesn't require fit-testing.
Project BREATHE (Better Respiratory Equipment using Advanced Technology for Healthcare Employees) involves a collaboration between the Veterans Health Administration and the National Institute for Occupational Safety and Health (NIOSH), which certifies respirators.
"We aim to bring together 10 or 15 different agencies in the federal government that will issue a consensus statement about the best characteristics to include in respirators for health care workers," says Lewis J. Radonovich, MD, principal investigator of Project BREATHE and director, Biosecurity Programs, for the Office of Program Development at the North Florida/South Georgia Veterans Health System in Gainesville, FL.
The working group also wants to identify barriers to new, health care-oriented designs and ways to overcome those barriers, he says.
NIOSH frequently receives queries from people who want to develop respirators out of new materials and using new designs, says Ron Shaffer, PhD, chief of the research branch of NIOSH's National Personal Protective Technology Lab in Pittsburgh. "We know people are thinking about it, but we don't see too many of those concepts making it into the market," he says.
NIOSH already is working on numerous respirator projects, including new fit criteria that would require respirators to fit most people well out of the box.
Project BREATHE is about innovation. It will bring together experts and pose the question:
"If you could start from scratch and design a product, what would those design attributes be?" he says. "We may come back with the same answer that it looks like a filtering facepiece respirator [the respirators most commonly used in health care]."
Respirator design is dictated by NIOSH certification requirements, says Janice Bradley, CSP, technical director of the International Safety Equipment Association in Arlington, VA, who notes that there are more styles and sizes available for N95 filtering facepiece respirators than any other type of respirator.
"Manufacturers design respirators to fit and be comfortable for as many users as possible, provide protection and achieve NIOSH certification," she says.
Respirator development for health care workers has been shaped by emerging infectious diseases.
In 1982, when the Centers for Disease Control and Prevention came out with Guidelines for Prevention of TB Transmission in Hospitals, few TB conversions were reported among health care workers and the agency recommended the use of surgical masks.
By the 1990s, amid a resurgence of tuberculosis, health care workers needed greater protection against a growing threat. In revised guidelines, CDC noted that "standard surgical masks may not be effective in preventing inhalation of droplet nuclei" and recommended the use of "particulate respirators." There actually were three types of disposable particulate respirators, all of which were designed for industry to protect against dust, mist, or fumes.1
"The health care work force essentially borrowed the respirators from other occupational sectors. At the time, there wasn't more effort put into developing a unique respirator for health care workers. We want to take that time now and revisit the issue," says Radonovich.
Similarly, health care workers at greater risk such as those performing intubations sometimes used powered air-purifying respirators, although PAPRs also were designed for industrial use. They were made for workers performing moderately exerting tasks and were tested for their ability to filter out silica dust and dioctyl phthalate. That meant they had an air flow rate of 170 liters per minute for loose-fitting respirators and a noise level of up to 80 decibels.
"Given that the sound level of normal voice communication in a quiet room at a distance of 3 feet is about 60 [decibels], it would be extremely difficult for a health care worker wearing a PAPR with a background sound level of 80 [decibels] to be able to hear a patient, let alone heart or lung sounds. Because of the differences between the industrial and healthcare environments, the current NIOSH performance requirements are not appropriate to PAPRs used by health care workers," an Institute of Medicine panel concluded in a 2008 report, Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers.2
N95s are physically uncomfortable
The outbreak of severe acute respiratory syndrome (SARS) in 2003 highlighted both the protective capability and drawbacks of N95 respirators. Consistent use of N95s was found to be effective during the SARS epidemic, but health care workers were confused about the proper way to remove their personal protective equipment.2 In one study, 93% of doctors and nurses said the N95 was physically uncomfortable and 47% said they had difficulty communicating with the respirator.3
As hospitals prepare for an influenza pandemic, NIOSH has launched several research projects to look at the effectiveness and wearability of N95 respirators.
The VHA, the nation's largest health care system, also has been looking into the respiratory protection needs of health care workers. In one project, health care workers in Gainesville and Lake City, FL, wore the N95 respirators for their entire work shifts to assess tolerance. The results of that study are forthcoming soon, Radonovich says.
Concerns about discomfort of respirators during long-term use underscore the need for Project BREATHE to produce a better respirator. The working group hopes to develop a white paper by this summer and make recommendations about creating a prototype that will be lab-tested and piloted in one or more hospitals.
"What we're trying to prevent is the awful situation in which a health care worker takes off his or her protective equipment because it is uncomfortable and gets exposed to a terrible illness," says Radonovich. "In my experience, health care workers feel a tremendous sense of dedication to their patients and [to] performing their job diligently. If they believe a protective device is interfering with doing their job in a proficient manner, they may remove it."
Project BREATHE reflects an effort to bring the consumer perspective into respirator design. "We're not necessarily assuming that what's in the marketplace is insufficient," he says. "However, we believe that there probably are some relatively high-yield modifications that could be made to respirators that wouldn't necessarily increase the cost or the amount of resources that would need to be expended by a health care system."
References
1. Jarvis WR, Bolyard EA, Bozzi CJ et al. Respirators, Recommendations, and Regulations: The controversy surrounding protection of health care workers from tuberculosis. Ann Intern Med 1995; 122:142-146.
2. Institute of Medicine. Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers. Goldfrank LR, Liverman CT, eds. Washington, DC: The National Academies Press; 2008. Available at http://books.nap.edu/openbook.php?record_id=11980. Accessed on May 13, 2008.
3. Nickell LA, Cirhgton EJ, Tracy CS, et al. Psychosocial effects of SARS on hospital staff: Survey of a large tertiary institution. CMAJ 2004; 170:793-798.
If you could give health care workers the ideal respirator, what would it look like? For the first time, an interagency task force is considering that question in a project they hope will result in a more effective, less cumbersome respirator perhaps one that doesn't require fit-testing.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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