Hands-on Training 

By Michael J. Bmich, Jr. and Henry J. Kellner, Jr. 

UNITED STATES DEPARTMENT OF THE INTERIOR 

Manuel Lujan, Jr., Secretary 

BUREAU OF MINES 

T S Ary, Director 
Library of Cangscess Ctatallogirng in Publicaticbaa Data: 

Brnich, M. d. 

Cleaning, disinfecting, and sterilizing self-contained self-rescuer mouthpiece 

assc~nblies used in hands-on training / by Michael J. Brnid~ and I-lcnry 3. Kcltner, 

Jr. 

p. cm, - (13ureau of Mines information circular) 

lncludes bibfiographical references. 

1. Self-contained self-rescuer (Mine rescue equipment)-Safety measures. 2. 

Communicable diseases-Prevention. I. Kellner, H. J. 11. Title. 111. Series: 

fnformation circular (United, States. Butcau of Mines); 9236 

TN29S.U4 [TN297] 622 s-dc20 [614.4'8} 89-600276 

CXP 
CONTENTS 

Page 

Abstract ........................................................................... fntroduction ...........................................'............................. 

Backgo~nd .............................................................*.......... 

Sterilization ........................................................................ Dishfeation and cleaning .............................................................. Dentalprufession .................................................................. Cardiopulmonary resuscitation training .................................................. Sc~1batrainhg .................................................................... Methods used jin mining ............................................................. Self-contained self-rescuer mouthpiece testing ............................................... DiScussi~n .......................................................................... C~ticlusions ........................................................................ References ......................................................................... 

TABLE 

1 . Guide to chemical agents for disinfection and/or sterilization ................................ 3 
UMfT OF MEASURE ABBREVlATRONS' USED IN THIS REPORT 

OF degree Fahrenheit 

gal gallan 

h: hour 

Hz hertz 

min minute 

ppm. part per million 
CLEANING, DISINFECTING, AND STERILIZING 

SELF-CONTAINED SELF-RESCUER MOUTHPIECE ASSEMBLIES 

USED IN HANDS-ON TRAINING 

By Michael J. Brnich, ~r.' and Henry J. Kellner, dr.* 

ABSTRACT 

This U.S. Bureau of Mines report addresses issues involved in using a limited nurnbcr of training 

apparatus to give hands-on self-contained self-rescuer (SCSR) training to a successitsn of miners, and 

provides guidance regarding methods for minimizing the spread of infectious diseases. Procedures used 

for preventing the spread of infectious organisms in dentistry, cardiopulmonary resuscitation (CPR) 

training, and scuba training are examined. The sanitizing methods of three organizations that require 

individuals to insert the mouthpiece as part of the SCSR donning sequence are discussed. It was found 

that each of these organizations was abIe to render their mouthpiece assemblies microbe free simply and 

inexpensively . 

'~ining engineer. 

21ndtrstxia~ engineering tcchrrician. 

P'ittsbugh Research Center, U.S. Bureau of Mines, Pittsburgh, PA. 
En June 1987, the Mine Safety and Health Administration (MSHA) issued an Emergency Temporary Standard 

(ETS) requiring hands-on SCSR training for all persons 

entering underground mines (I)? The ETS specifies four 

elements that must be included in SCSR training. These 

are as follows: (1) Opening the device; (2) activating the 

oxygen; (3) inserting the mouthpiece or simulating this task ' 

while explaining the procedure; and (4) putting on the 

noseclips. 

Studies of miners putting on the SCSR indicate that the 

fa3ure to obtain a good seal on the mouthpiece is a fairly 

common error, which can be temedlied and corrected 

through additional hands-on practice (2). Sirnulatian of 

this task obviously provides no feedback, thus leaving in 

doubt the trainee's ability to complete this critical task 

during an actual mine emergency. Therefore, many mine 

trd'mers adopt a training strategy that includes insertion of 

the mouthpiece. This permits the practice of the entire 

sequence including breathing through the SCSR training 

apparatus. 

The use of a single training apparatus to provide handson training for several miners presents a problem. There , ' 

are widespread concerns over the spread of infectious 

organisms st1cJ.1 as hepatitis B, herpes, and acquired immune deficiency syndrome (AIDS). Mine trainers seek 

methods for protecting miners as well as themselves from . . 

,contracting these diseases during SCSR training. These 

concerns parallel similar expressions by individuals working 

in the medical and dental. communities. This U.S. Bureau 

of Mines report explores the issues involved and provides 

guidance regarding the use of methods for minimizing the 

spread of infectious diseases during hands-on practice. 

The terms ster.ilization, disinfection, and cleaning have 

different definitions, but quite often these terms are misused and ititerchanged. Sterilization is defined as the use 

of same form of cllernicat or physical method to destroy all 

microbial life, including high1y resistant bacterial endospores (3). In effect, a sterilized object will remain sterile 

as long as it is kept in a sterile environment. Obviously, 

* the process of sterilizing is more complex than disinfecting. 

Disinfection is defined as a process that inactivates nearly 

all pathogenic micro-organisms, but not all microbial forms 

(bacteriai eadospores) an inanimate objects (3). All other 

treatments come under the category known as cleaning 

which, in itself, can be usefuI. Table 1 provides a listing of 

chemical agents used in disinfection and/or sterilization; a 

chemical classification for these agents; and corresponding 

disinfe~tant and/or sterilant characteristics. 

Many mine trainers have their trainees demonstrate the 

motor task of mouthpiece insertion. Consequently, a few 

mouthpiece assemblies may be used by many individuals 

in hands-on SCSR training. Therefore, it was decided that 

tho researchers should review methods for preventing the 

spread of infectious organisms in other settings in which 

objects that cantact mucus membranes of the body are 

used to serve the needs of many people. Techniques used 

far abating the spread of infectious organisms in dentistry, 

3~talic numbers in parentheses refer to items in the list of ~eferences 

at tho end of this x;eprt. 

ClPR training, and scuba diving were assessed to determine 

the feasibility of using these techniques in hands-on SCSR 

training. 

Methods for preventing the transmission of infectious 

diseases in the dental profession have been reviewed in 

earlier studies (4-5). Information currently available for 

the dental profession discusses modes of transmission of 

infectious diseases. The information also reviews methods 

for prevention of transmission of such diseases including 

the use of sterilization, disinfection, and thorough cleaning 

of instruments, equipment, and work areas. Research 

focusing on disease transmission in CPR training was 

examined (6-7). The information reviewed discusses techniques that reduce the possibility of disease transmission. 

These methods include the use of protective equipment 

(face shields or masks) by trainees, simulation of rescue 

breathing in two-rescuer CPR training to reduce manikin 

contact, and procedures for decontaminating manikins 

once they are used. 

Finally, research addressing the topic df disinfection 

procedures for scuba equipment was reviewed (8). Although there are a number of diving training and certification agencies in addition to equipment manufacturers, 

the literature indicates there are no standardized recommendations for decontamination of shared scuba equip 

ment. However, the literature does discuss mcthods that 

can be used for adequate cleaning and disinfection of 

shared scuba equipment used in training and rental 

settings. 
Table l .-Guide .ta chemical agents for disinfection and/or sterilization 

Acceptad Chemical Disinfectant Ill_-L.l._l. 

Sterilant 

praducts classification 

ProMed brand ' lodophors, 1 % Diluted according 

Wascodyna-D available iodine. to manufacturer's 

.NAP 

.B~acids.~ 

Housahold 

bleach. 

Dentassptic 

Multicide! 

Omni It, 

$poricidtn . . , . 

cer?tra2 

Cidex 7 

Sodium hypochlorite. 

o-phertytphenol, 9% and 

o-benzyl-p-chlorophenol, 1 %. 

Glutaraldehyde 2% 

alkaline with 

phenolic buffer. 

Glutaraldehyde 2% 

neutral. 

Gtutaraldehyde 2% 

acidic potentiated 

with nonionic 

ethoxylates of 

linear alchohals 

Chtorlns dioxide . , , . . . . , 

Glutataldehyde 2% 

alkalins. 

instructions, 30 min. 

Diluted 1:s to 2:100,~ 

10 to 30 min, 

Diluted 1:32, 

10 min at room 

temperature. 

Diluted 1:16, 

10 min at room 

temperature, 

Full strength, 

10 mln at room 

temperature. 

r>iluted 1:2, 

10 rnin at room 

temperature. 

2 min at room 

temperature. 

Full strength, 

10 min at room 

temperature. lYYUYI v CII 

Not apploable. '80 used bleach to water. 

'~vailable in regular (Id-day activity) or long life (28day activity). 

Full strength, 

6-3/4 h at room 

temperature. 

Full strength, 

10 h at room 

temperature. 

Full strength, ' I hat 140°F 

4hat104" , 

to 122" F, 10 h 

at room 

temperature, 

6 h at room 

temperature. 

Full strength, 

10 h at room 

temperature, 
Severat types of sterilization procedures are employed 

in the dental profession to sterilize instruments and equipment used. These techniques 'mciude hot sterilization 

using steam or dry heat, gas sterilization, and chemical 

cold sterilizatioxl. Ster ilizatiotl is not used in CPR training, 

nor is it advocated for use with scuba diving equipment. 

Hot sterilization involves the use of pressurized steam 

in a steam autoclave or the application of dry heat. For 

proper sterilization to occur, the temperature inside the 

steam autoclave must be from 250" to 2700 F. When dry 

heat sterilization is used, temperatures must range from 

340" P for 1 h to 250' F for I6 h. For gas stexilizatian, 

instruments are placed in ethylene oxide gas sterilizers. 

For gas systems, special piping and other provisions including venting to the outside are required because the 

gas is toxic. Cold sterilization uses liquid ckenlicals and is 

employed for heat-sensitive instruments or objects. 

DIISIINFECTBON AND CLEANBING 

Several methods are employed for conducting disinfection cleaning in the dental prof~ssion, CPR training, scuba 

training, and in annual refresher SCSR training for miners. 

Methods far disinfection include high-level disinfection 

using disinfectant-sterilant chemicals registered by the U.S. 

Environmental Protection Agency (EM) or boiling water 

and disinfection using chemical germicide solutions. Several rncthucls are available for cleaning dental instruments 

and other objects. These methods indude thorough washing ancf .~rltrar,nic cleaning. Ultrasonic cleaning is a technique in which objects are immersed in a liquid cleaning 

medium that is aided by ultrasonic waves (waves greater 

than 16,000 Hz) generated by the cleaning vessel. 

DENTAL PROFESSfBN 

High-level disinfection can be accomplished by immersion in either boiling water for at least 10 min or an EPAregistered disinfectant-steraant chemical for the exposure 

time recommended by the chemical's manufacturer. Disinfection can also be done with suitable chemical germicides. 

For disinfection of work areas in dentistry, a solution of 

s~dium hypochlorite (household bleach) prepared fresh 

daily is recommended as an inexpensive and effective 

germicide. Breach-water concentrations that range from 

5,000 to 500 ppm (1:10 to 1:100 dilution of bleach) are 

effective9 depending on the amount of organic material on 

the surface to be cleaned and disinfected. 

Before disinfection or sterilization of instruments can 

take place, they must be thoroughly cleaned to remove 

blood, saliva, and other substances that are present. 

Clcanitlg can be accomplished in several ways. First, one 

can clean by thtoroughfy scrubbing instruments with soap 

and water or 'a detergent. All adherent debris must be 

removed, the instruments thoroughly rinsed, and then 

dried. Cleaning can also be accomplished by using mechanical devices such as ultrasonic cleaners. 

CARDIOPULMONARY RESUSCPTAPBON 

THAI Nll NG 

Xn 1983, an ad hac coamittee for evaluating sanitary' 

practices in CPR trainjmg was formed and developed recommendations for decontaminating manikins used in CPR 

training. The committee was comprised of representatives 

from the American Heart Association, the American Red 

Crass, and the Centers for Disease Control. The committee recommended that CPR manikins be disassembled,' 

thoroughly washed, and rSnsed. Following washing, all 

surfaces capable of disease transmission are to be wet for 

10 min with a sodium hypochlorite solution containing at 

least 500 ppm free available chlorine (1/4 cup household 

bleach per gallon of tap water). FoIlowing use of the 

bleach and water solution, the parts are to ba rinsed thoroughly with tap water and dried. This bleach solution 

must be made fresh for each ClPR class and discarded 

after use. 

Cleaning standards for CPR manikins closely follow 

those advocated for the dental profession. CPR instructors 

are advised to disassemble the manikins according to the 

manufacturer's directions. The components are to then be 

thoroughly washed with warm soapy watei, The manikin 

parts are to be scrubbed with a brush to remove all saliva 

and other substances. Once washed, the parts can be 

rinsed with tap water and allowed to air-dry, 
In 1985, inquiries began to increase regarding the adequacy of fbe standards recommended for manikin &contamination in k2bg the AIDS vird agent. Subsequent 

studies revcaled that the vird agent causing AIDS, human 

T-cell lymphotropic virus type III-lymphadenopathyassociated virus (IXTLV-III-LAV), is delicate and is inactivated at room temperature in less than 10 min by a number of disinfectant chemical solutions including sodium 

hypoddaritc. 

The bleach dilution, used in conjunction with thorough 

scrubbing and rinsing, will ensure that the HTLV-111-LAV 

virus and a variety of other infectious agents will be killed, 

The: literature indicates that 8 the recommended decontamination procedures are foUowed consistently in CPR 

training, students will use manikins that have a sanitary 

quality equal to or better than that of eating utensils found 

In restaurants. 

SCUBA TRAINING 

In scuba trirhing and scuba equipment rental, the use 

d shared equipment is common. As mentioned earlier, 

literature hdieates that there are no formal standards for 

decontaminating shared scuba equipment. It is known that 

in certified, nationally recognized diving courses, training 

is required to be conducted with special diving equipment 

having a second regulator-mouthpiece and hose assembly 

attached to the primary air tank regulator. With this type 

of equipment, each diver win have his or her own mouthpiece during training. As a result, the risks of disease 

transmission are reduced. 

The Centers for Disease Controt have made some 

rcconnrnendadoas for decontminating scuba mouthpieces. 

These recommex1datians incfude thorough cleaning of the 

devices followed by disinfection. Disinfection can be accomplished by immersing the mouthpiece in some broadspectrum germicidal solution. Exposure to a fresh solution 

d household bleach (1/4 cup bleach in 1 gal of tap water) 

fbr 10 min is considered sufficient for disinfection. Following disinfection, the mouthpieces can be rinsed with 

fresh tap water and permitted to air-dry. 

Manufacturers of scuba equipment have recommended 

fhat devices be rinsed thoroughly with fresh tap water. 

For shared equipment, it is recommended that the mouthpieces be removed from the unit and thoroughly scrubbed 

with soap and warm water. Brushes should be used to 

scrub away substances found on the surfaces of the 

mouthpiece and to adequately scrub the breathing hoses. 

Following scrubbing, the mouthpieces can be rinsed with 

fresh tap water and permitted to air-dry. 

METHODS USED IN MINING 

The cleaning procedures used by three mining organizations in preventing the spread of infectious diseases 

during SCSW training are described below. These thee 

organizations are providing a method of hands-on training 

that requires individuals to insert the mouthpiece as part 

of the training sequence. 

Organization A: Since July 1986, Organization A has 

been involved in hands-on SCSR training for its personnel 

using three Draeger4 OXY-SR 60B training apparatus 

modified to permit quick changeout of mouthpiece assemblies. Twenty additional mouthpieces were purchased, 

permitting a clean assembly to be installed before each 

use. Following use, the mouthpiece assemblies were removed, scrubbed in soap and water, and rinsed. Following 

rinsing, the assemblies were then soaked overnight in a 

chemical sterifant solution known as Cidex 7. The assernblies were then removed from the sterilant solution, thoroughly rinsed with water, and permitted to air-dry. 

Organization B: Trainers purchased 27 extra mouth- ' 

piece assemblies for use with 6 to 12 CSE AIJ-9Al training models. Used assemblies are removed, cleaned, and 

then disinfected by soaking in a household bleach-water 

solution for 30 to 45 rnin. Trainers mix the bleach-water 

solution at a ratio of approximately 1 part bleach to 

10 parts warm water (5,000 pprn bleach solution). After 

soaking, the mouthpiece assemblies are rinsed with warm 

water and are allowed to air-dry. 

Organization C: This organization chose to purchase 

mouthpiece assemblies for each of the employees receiving 

bands-on training at their operation. Nearly 100 Draeger 

OXY-SR 60B assemblies were bought and each was engraved with a serial number to identify the worker who 

used it. After use, the assemblies were cleaned in a soapwater solution and then packaged each in a separate plastic storage bag. The mouthpieces were not disinfected or 

sterilized in any form. Trainers maintain the mouthpiece 

assemblies for reuse during followup evaluations. The 

organization felt that with this program, it could ensure 

each miner that an individual would use only his or her 

own mouthpiece. 

'~eference to specific products does not ,imply endorsement by the 

U.S. Bureau of Mines. 
In early 1988, the, Bureau obtained a random sample of 

four mouthpiece assemblies from organization A, four 

from organization 33, and five from organization C. As 

mentioned earlier, organization A used a chemical cold 

stmilant for mouthpiece assemblies and organization B 

used a bleach-water solution to disinfect;. Organization C 

cleaned their assemblies with a soap and water solution. 

An independent biological testing laboratory conducted 

tosts for mi~~a-organisms oneach mouthpiece assembly. 

TWO major tests were conducted. The fxst was a standard 

plate count, which is a broad-spectrum bacteria test. The 

second was an anaerobic plate count for determining the 

presence of organisms that grow in oxygen-free environments. Test results indicated that, for each mouthpiece 

tested, a count of fewer than 100 organisms per milliliter 

of sterile water was observed for both types of plate 

counts. For drinking water, the legal safe limit for microorganisms is 500 per milliliter of sterile water, These 

results indicate that each mouthpiece tested was free of 

micro-organisms, regardless of which cleaning-disinfectingsterilizing method was used. 

The methods for cleaning and disinfecting SCSR 

mouthpiece-hose assemblies reviewed in this report are 

procedures currently used by trainers. Other methods may 

be practiced. For example, organization A originally 

rinsed used mouthpieces with water, immersed the assemblies in rubbing alcohol (70% alcohol) for several minutes, 

and then permitted them to air-dry. Many trainees cornpfaincd of the foul. taste of alcohol left on the mouthpiece 

after deadng, however. Later, this organization switched 

to rinsing the mouthpieces and soaking them in a soap 

solution. Following irnrnersi6n in the soap and water 

solution, the mouthpieces were rinsed thoroughly with 

water and permitted to air-dry. Finally, the trainers began 

using the Cidex 7 solution discussed above. 

In August 1987, Bureau personnel investigated the 

possibility of using hot (steam) steritization for sanitizing 

SCSR mouthpieces. Several Draeger mouthpiece assemblies were placed into a steam autoclave in an attempt to 

sterilize them. When the mouthpieces were removed from 

the autoclave, major deformation of tlie plastic parts of the * 

assemblies was noted. Hot sterilization is therefore imprafticd because of heat damage to the mouthpiece assemblies. Gas sterilization may not be feasible since 

special piping, venting, and other provisions are required. 

Based on this review of available information, the approach at the Bureau in the future wiH be to use a thorough cleaning process foHaw:d by immersion in a bleachwater sofution for disinfecting SCSR mouthpieces. This 

farm of cleaning and disinfection is not expensive. This 

recomrncndation is based upon the results of microbial 

testing and similar procedures advocated for disinfecting 

CPR and scnba training equipment. These procedures are 

thought ta be effective in abating the spread of infectious 

dis~ase, 

Chemical cold stexilants, which are not prohibitively 

expensive, could also be used. With respect to SCSR 

mouthpiece assemblies, microbial test,results indicate that 

there is no advantage for sterilization over disinfection. At 

the same time, chemical sterilants are not readily available 

and must be purchased from medical supply houses. Ultimately, the trainer must decide if individual mouthpieces 

will be used or if mouthpieces will be shared by trainees. 

This decision will dictate the type of cleaning and/or disinfection routine that will be used. 

It is hoped that this report will. provide mine trainers 

and others with useful information for adequately cleaning 

and disinfecting SCSR mouthpieces to aid in preventing 

the spread of infectious disease during hands-on SCSR 

training. 
REFERENCES 

1. Ffedeual Register, U.S. Mine Safety and Health Administration 

(Dep Labor), Underground Coal Mining; Self-Contained Self-Rescue 

Devices: Emergency Temporary Standard and Proposed Rule. V. 52, 

NO. IS, June: 30, 1987, pp. 24374-24380. 

2. Vaught, C, M. J. Brnich, and H. J. KeHner. Effect of Training 

Strategy on Self-Contained Set€-Rezrcucr Donning Performance. Paper 

in Mine Safcty Education and Training Seminar. Proceedings: Bureau 

d Mines Technalagy Transfer Seminar, Pittsburgh, PA, Nay 17,1988; 

Becklcy, WV, May 13, 1988; St. Louis, MO, May 24, 1988; and Reno, 

NV, May 26,1988. BuMines XC 9185,1988, lpp. 2-14. 

3. Favero, Martin S. Sterilization, Disinfection, and Antisepsis in 

the Hospital. Ch. in Manual of Clinical Microbiology, ed. by E. H. 

hnnette, A. Ralows, W, J. Hausler, Jr., and H: J. Shadomy. Am. Soc. 

Microbial., 4th cd., 1985, pp. 129-137. 

4. Ammican Rental Association (Chicago, IL). Facts About AIDS 

far Dental Professionals. AJUA, Nov. 1985, 8 pp. 

5. Centers for Disease Control (Atlanta, GA). Prcvextting the 

Transmission of Hepatitis B, AIDS, and Herpes in Dentistry. CDC 00- 

4846, 1985, 13 pp: 

6. American Heart Association. Standards and Guidelines for 

Cardiopulmonary Resuscitation and Emergency Cardiac Care: Safety 

in Training for and Providing CPR JAMA, v. 255, No. 21, 1986, 

pp. 229264928. 

7. Skirtich, Sharon (Am. Red Cross). General communication 

regarding cleaning procedure for CPR manikins, June 1986; available 

upon request from S. Skirtich, ARC, Pittsburgh-Allegheny County 

Chapter, Pittsburgh, PA. 

8. Bond, Walter W, Disinfection of Scuba Diving Equipment. SAMA, v. 258, No. 23,1987, p. 3439.