Award Title: Measurement of the Aerosol Generating Potential of Intubation, Extubation and associated airway procedures – MAGPIE study
Funder: Department of Health and Social Care

Abstract: Research Question What are the relative risks of aerosol production from airway management techniques used during surgery or intensive care, and what strategies can be employed to reduce aerosol generation? BackgroundThe COVID-19 pandemic has had an unprecedented impact on global health and the world economy. The SARS-CoV-2 virus is highly contagious and the potential of airborne viral transmission from aerosols is a concern. Certain medical interventions, including those for anaesthesia and intensive care, are designated 'aerosol generating procedures' (AGPs) and deemed to carry increased risk of viral transmission. There is currently little to no quantitative evidence on the aerosolisation risk for many AGPs. Current national and international AGP guidelines are based on weak epidemiological evidence. Stringent measures introduced to minimise the potential risk of aerosolised SARS-CoV-2 transmission to staff and patients have reduced the ability of the NHS to restart important services including elective and cancer surgery. These methods have prolonged operations and reduced healthcare efficiency to 60% of capacity. 15bn has been allocated for PPE acquisition which is more than 10% of the annual NHS budget. Surgical waiting lists are expected to double by the end of 2020 from 4million to 10million patients The use of enhanced PPE:	Is hugely costly for the NHS 	Impairs communication between teams 	Increases the risk of medical errors 	Reduces staff and patient interactions 	Increases stress and anxiety for healthcare workers and patients 	Produces vast quantities of non-recyclable wasteThis study aims to quantify the aerosol generated by currently identified AGPs. Methods 	WS1 - MAGPIE studyWorking with the Bristol Aerosol Research Centre, I will use highly sensitive, accurate optical particle sizers to analyse the airborne particles generated by common AGPs used in anaesthesia and intensive care. This will quantitate aerosol concentration, size distribution and persistence of particles generated during these AGPs	WS2 -h; AGPercept surveyA national survey of medical professionals involved in performing AGPs will determine attitudes towards the risk of viral transmission and impacts of precautions against bioaerosols. This will be undertaken both before and after dissemination of the WS1 results to identify barriers to practice change.	WS3 -h; ROADMAP studyThis aims to identify and develop strategies to reduce aerosol production during airway management procedures to allow essential NHS services to get back on track Benefits to patients and the NHS within 24 months This research aims to quantify aerosols generated from current AGPs. If any investigated AGPs generate less aerosol than a standard cough, their relative risk of aerosolisation is low and may be declassified as an AGP. This would enable more appropriate risk assessment and mitigation, potentially yield huge-cost savings for the NHS and improve theatre efficiency enabling resumption of surgical services. Strategies will be explored to reduce the risk from AGPs identified as generating substantial aerosols to effectively prevent viral transmission. Dissemination will be undertaken to inform national AGP policies. Future Benefits Understanding the potential for aerosol generation will be useful in assessing the risk of transmission of other respiratory pathogens, including novel emergent viruses.

Lay Abstract: Aims of the Research	Measure the amount of particles (aerosol) released into the air during medical procedures 	Measure how long particles (aerosol) remain in the air following medical procedures 	Develop ways to reduce the amount of particles (aerosol) released into the air during medical proceduresBackground The COVID-19 pandemic has had a huge effect on global health and the world economy. Coronavirus spread during hospital procedures is a big concern. Safe delivery of essential NHS services is affected by the need to reduce coronavirus spread to staff and patients. Aerosols can be created during medical procedures and occur when tiny particles are suspended in the air. Aerosols can carry viruses, like the coronavirus. These aerosols may cause infection by allowing hospital staff or patients to breathe coronavirus into their lungs. Many operations need a general anaesthetic, where a patient is not awake for surgery. A breathing tube is placed to allow surgery to be performed. Insertion and removal of the breathing tube may produce an aerosol which risks spreading coronavirus to staff in the operating theatre. This risk means all staff present must wear enhanced personal protective equipment (PPE) such as 'respirator-type' face masks. It is unknown how much aerosol is produced for many procedures and how long aerosols remain in the air. The use of enhanced PPE:	Is expensive for the NHS 	Increases the risk of medical mistakes 	Reduces staff and patient contact 	Makes talking and hearing more difficult for healthcare workers and patients 	Increases stress and anxiety for healthcare workers and patients 	Is uncomfortable 	Makes teamworking more difficult 	Produces lots of non-recyclable wasteThe amount of PPE is limited. PPE needs to be used where it is most needed. At the moment, staff wear enhanced PPE for every patient having an operation to reduce coronavirus spread. Staff and patients are not allowed to move in or out of a room for 10 minutes at the start and end of surgery because of the risk from aerosols. This increases the time taken for every operation and has almost halved the number of patients having an operation each day. This includes operations for life-threatening conditions like cancer. Design and Methods This research will be performed with an experienced team of aerosol specialists and airway doctors. Workstream 1: Using highly accurate scientific equipment I will measure the amount of aerosol produced during medical procedures to help patients breathe. These procedures include insertion and removal of breathing tubes for patients having a surgical operation, and facemasks used on intensive care. Workstream 2: I will perform a national survey of medical staff at risk of viral infections from aerosols. The aim is to find out barriers that may prevent new guidelines being used. Workstream 3: I will produce methods to reduce aerosols when a breathing tube is inserted or removed Patient and Public Involvement I undertook a survey of local anaesthetists. The survey showed aerosols were their biggest concern for catching coronavirus. It also showed enhanced PPE increased stress and anxiety, increased the risk of mistakes and caused operations to take longer. Input from a patient representative in a local hospital was supportive:'Having read your proposal the benefits that would be created are clear. The loss or reduction of staff/patient contact is key in my view, certainly in terms of reassurance and also clear understanding of procedures taking place.' Dissemination The results will be shared with:	Participants 	Government policy makers 	The Royal College of Anaesthetists and Intensive Care Society 	Journals/conferences 	TwitterThe results will help produce regulations for safe NHS working, improve NHS efficiency, reduce non-recyclable waste and save the NHS money.

Research Activity Codes: 3.2 INTERVENTIONS TO ALTER PHYSICAL AND BIOLOGICAL ENVIRONMENTAL RISKS
Health Categories: INFECTION