Risk of transmission of respiratory viruses during aerosol-generating medical procedures (AGMPs) revisited in the COVID-19 pandemic: a systematic review

Leal, Jenine; Farkas, Brenlea; Mastikhina, Liza; Flanagan, Jordyn; Skidmore, Becky; Salmon, Charleen; Dixit, Devika; Smith, Stephanie; Tsekrekos, Stephen; Lee, Bonita; Vayalumkal, Joseph; Dunn, Jessica; Harrison, Robyn; Cordoviz, Melody; Dubois, Roberta; Chandran, Uma; Clement, Fiona; Bush, Kathryn; Conly, John; Larios, Oscar

doi:10.1186/s13756-022-01133-8

Antimicrobial Resistance & Infection Control

Table 4 Summary of findings from the studies that included statistical comparisons with respect to transmission of COVID-19 during specific AGMPs*

From: Risk of transmission of respiratory viruses during aerosol-generating medical procedures (AGMPs) revisited in the COVID-19 pandemic: a systematic review

AGMP	HCW role during AGMP	Author	Study design	Sample size	Odds ratio^a (95%CI)
Airway Suctioning	Participated in	Nakagama [45]	Prospective cohort	AGMP: n = 202 Control: n = 202	RR: 1.67(NR); p = 0.04
	NR; sputum suction	Ran [42]	Retrospective cohort	AGMP: n = 11 Control: n = 61	RR: 0.43 (0.12 to 1.55)
	Performed or assisted, or present in room	Heinzerling [48]	Cohort	AGMP: n = 7 Control: n = NR	AGMP cases: 0 Control cases: NR p = 1.00
	NR	Chatterjee [28]	Case–control	AGMP: n = 35 Control: n = 716	0.73 (0.37 to 1.45)
	Performed open suctioning	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.55 (0.3 to 1.01)
	Performed closed suctioning	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.89 (0.57 to 1.39)
Broncho-Alveolar Lavage	Performed (> 5 times)	Lormans [36]	Cohort	AGMP: n = NR Control: n = NR	0.42 (0.05 to 3.53)
Bronchoscopy	NR	Ran [42]	Retrospective cohort	AGMP: n = 1 Control: n = 71	RR: 0.63 (0.06 to 7.08)
	Performed or assisted	Heinzerling [48]	Cohort	AGMP: n = 3 Control: n = NR	AGMP cases: 0 Control cases: NR p = 1.00
	Present in room	Heinzerling [48]	Cohort	AGMP: n = 3 Control: n = NR	AGMP cases: 0 Control cases: NR p = 1.00
	Performed rigid bronchoscopy	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.256 (0.03 to 2.0)
	Witnessed/assisted rigid bronchoscopy	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	1.09 (0.3 to 4.0)
	Performed	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.55 (0.3 to 1.03)
	Witnessed/assisted	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.7 (0.32 to 1.51)
	Performed	Caglayan [34]	Cross-sectional	AGMP: n = 31 Control: n = 122	AGMP cases:3 Control cases:5 p = 0.21
CPR	Participated in	Nakagama [45]	Prospective cohort	AGMP: n = 13 Control: n = 202	RR: 1.94 (NR); p = 0.214
	NR	Ran [42]	Retrospective cohort	AGMP: n = 1 Control: n = 71	RR: 0.63 (0.06 to 7.08)
	Performed	Celebi [29]	Case–control	AGMP: n = 20 Control: n = 161	AGMP cases:6 Control cases:41 p = 0.629
	Advanced airway throughout	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	1.06 (0.5 to 2.25)
	No advanced airway at some point	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	1.32 (0.61 to 2.86)
Extubation	NR	Ran [42]	Retrospective cohort	AGMP: n = 1 Control: n = 71	0.63 (0.06 to 7.08)
	Performed	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.55 (0.25 to 1.24)
	Witnessed or assisted	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	1.29 (0.68 to 2.47)
Intubation/Extubation	Participated in	Nakagama [45]	Prospective cohort	AGMP: n = 21 Control: n = 202	RR: 0.8 (NR); p = 1
Intubation	Performed or assisted	Heinzerling [48]	Cohort	AGMP: n = 2 Control: n = NR	AGMP cases: 1 Control cases: NR p = 0.16
	Present in room	Heinzerling [48]	Cohort	AGMP: n = 1 Control: n = NR	AGMP cases: 0 Control cases: NR p = 1.00
	Performed (> 1 time)	Lormans [36]	Cohort	AGMP: n = NR Control: n = NR	0.23 (0.03 to 1.98)
	Performed or present in room	Celebi [29]	Case–control	AGMP: n = 27 Control: n = 154	AGMP cases:6 Control cases:41 p = 0.705
	NR	Chatterjee [28]	Case–control	AGMP: n = 31 Control: n = 720	2.5 (1.13 to 5.5)
	Performed	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.73 (0.38 to 1.37)
	Witnessed or assisted	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.74 (0.44 to 1.26)
Manual Ventilation	Participated in	Nakagama [45]	Prospective cohort	AGMP: n = 19 Control: n = 202	RR: 3.1(NR); p = 0.008
	Performed or assisted, or present in room (BiPAP, CPAP)	Heinzerling [48]	Cohort	AGMP: n = 6 Control: n = NR	AGMP cases: 2 Control cases: NR p = 0.06
	Performed or assisted, or present in room	Heinzerling [48]	Cohort	AGMP: n = 3 Control: n = NR	AGMP cases: 1 Control cases: NR p = 0.23
	Adjusted NIPPV mask	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.6 (0.38 to 0.95)
	Present during use of NIPPV	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.71 (0.49 to 1.04)
Mechanical Ventilation	Present in room	Celebi [29]	Case–control	AGMP: n = 42 Control: n = 139	AGMP cases:9 Control cases:38 p = 0.484
Nebulizer	Administration	Nakagama [45]	Prospective cohort	AGMP: n = 8 Control: n = 202	RR: 1.05(NR); p = 1
	Sputum induction	Nakagama [45]	Prospective cohort	AGMP: n = 12 Control: n = 202	RR: 2.8(NR); p = 0.055
	Performed or assisted, or present in room	Heinzerling [48]	Cohort	AGMP: n = 5 Control: n = NR	AGMP cases: 2 Control cases: NR p = 0.04
	Present during delivery	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	1.11 (0.69 to 1.8)
Oxygen administration	Applied or adjusted patient's HFNC	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.98 (0.65 to 1.47)
Oxygen administration	Present during use	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	1.05 (0.74 to 1.47)
Tracheostomy	Oxygen supplementation via tracheostomy	Nakagama [45]	Prospective cohort	AGMP: n = 63 Control: n = 202	RR: 1.07 (NR); p = 0.83
	Exposed to with any role (first operator, fiberoscopist, instrumental nurse, or anesthesia nurse)	Rosano [38]	Cohort	AGMP: n = 91 Control: n = 52	AGMP cases:7 Control cases:6 p = 0.55
	Performed open tracheostomy	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	1.04 (0.21 to 5.03)
	Witnessed or assisted open tracheostomy	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.99 (0.27 to 3.58)
	Performed percutaneous tracheostomy	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.45 (0.06 to 3.63)
	Witnessed or assisted percutaneous tracheostomy	Lentz [32]	Case–control	AGMP: n = NR Control: n = NR	0.78 (0.22 to 2.72)

Bolded estimates represent statistically significant results (p < 0.05). Details pertaining to patients and settings and studies that only reported count data but no statistical comparisons can be found in Table 2
AGMP aerosol-generating medical procedure; CI confidence interval; HCW healthcare worker; HFNC high flow nasal cannula; NIPPV noninvasive positive-pressure ventilation; NR not reported; RR risk ratio
^aUnadjusted Odds Ratio and 95% confidence interval unless otherwise specified

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