Feasibility of cleft lip and palate repair in personal protective equipment (PPE)

Abstract

Elective surgery during the evolving COVID-19 pandemic presents unprecedented logistical challenges to surgical teams. Cleft surgery may be considered an aerosol generating procedure (AGP), which may lead to small-droplet transmission of virions. Strict adherence to personal protective equipment (PPE) policy is used with the hope of preventing transmission of the virus between patients and operating theatre staff. The World Health Organisation (WHO) guidance for infection prevention and control during health care when COVID-19 is suspected recommends that healthcare workers performing AGPs should use a half-face particulate respirator at least as protective as a European Union (EU) standard Filtering Face Piece 2 (FFP2) respirator or equivalent. 1 Public Health England have published extensive guidance on PPE and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) has provided interpretation of this for plastic surgeons. 2 Recently published safety recommendations for ear, nose and throat surgery (ENT) also provide useful guidance for plastic surgeons who perform AGPs. 3 The most common types of respirators in healthcare are filtering facepiece (FFP) respirators and powered air purifying respirators (PAPRs). A PAPR is a battery-powered, air-purifying respirator that uses a pump to force air through filter cartridges and into the breathing zone of the wearer within a loose fitting hood. 4 PAPRs provide a higher assigned protection factor to the wearer than a FFP respirator. We sought to investigate compatibility of FFP3 respirators and PAPRs with surgical loupes and the operating microscope, as well as to examine the logistics of performing cleft surgery under these conditions. A group of cleft surgeons, head and neck surgeons and paediatric dentists attended a PPE workshop at The National Surgical and Clinical Skills Centre (NSCSC) in the Royal College of Surgeons in Ireland on 23 April 2020. Participants had the opportunity to try FFP3 respirators (Biztex Portwest, Westport, Mayo, Ireland) and PAPRs (3M Scott, Monroe, North Carolina, USA). Participants brought their own loupes and performed tasks in the surgical skills lab, before joining anaesthetic and nursing colleagues in a simulated operating room for a tracheostomy insertion, cleft palate repair and dental examination under general anaesthesia. A brief summary of observations is presented below. The workshop was run as part of an ongoing study into the use of PAPRs for AGPs in all surgical specialties, initiated by the UCD Centre for Precision Surgery, University College Dublin, Ireland. This wider study looked at multiple factors relating PAPRs usability in laparoscopic procedures as well as the head and neck procedures described here and a more detailed report of the combined data will be presented elsewhere in due course. FFP3 respirator: • FFP3 respirators tended to cause more facial discomfort than PAPRs. • Only one type of FFP3 respirator was available on the day and not all participants could achieve an adequate seal with this model. This highlighted the need for a variety of brands/models/sizes to be available in operating theatres. Fit-testing and training in seal-checking for all staff members by an appropriately trained fitter will be required on an ongoing basis in hospitals (it is a requirement of EU regulation of these devices that users be fit-tested annually). • FFP3 respirators tended to sit higher on the nose than regular surgical masks, which interfered with correct positioning of loupes for some participants. • The combination of FFP3 respirator and elasticated sports goggles was comfortable when using an operating microscope (Fig. 1 ). Figure 1 The combination of FFP3 respirator and elasticated sports goggles was compatible with the operating microscope, when trialled in the surgical skills lab. Figure 1 PAPR: • PAPRs were not compatible with the operating microscope. • Spectacles, standard 2.5-3.0X loupes and prism-amplified loupes were comfortable when worn in combination with PAPRs (Fig. 2 ). Spectacles and loupes necessitated using a full hood PAPR to maintain an adequate seal around the temple of the glasses. Figure 2 Operators wearing full-hood PAPRs, facemasks and spectacles or 2.7X loupes during simulation of cleft palate repair under general anaesthetic. Note that PAPRs do not filter the discharged air and therefore a regular surgical mask is also required in order to prevent droplet transmission from the user. Figure 2 • Expanded field telescope loupe designs were not compatible with the PAPR as the telescope tips touched against the visor, impeding correct positioning of the bridge/nose pads of the loupes. • It was felt that switching between FFP3 respirator/goggles/microscope to PAPR/facemask/loupes during a case (e.g. for oral layer suturing following palate muscle dissection) would be cumbersome and time consuming. • While fit-testing is not necessary for PAPRs, training in donning/doffing is essential, as well as adequate space and assistance in theatre prep rooms to carry out these processes safely. Operating room simulation in PAPRs: • Hearing and verbal communication were significantly hindered by full-hood PAPRs. • There was no difficulty in positioning the patient head down, inserting the gag or performing the manoeuvres of a palate repair while both surgeon and assistant were wearing full-hood PAPRs (Fig. 2). While public health and institutional guidelines will be the basis for decision-making in PPE use, it is important that surgeons have options available to them that are compatible with their subspecialty needs. We have explored several options for comfortably performing cleft surgery in PPE. Surgeons can anticipate a learning curve when starting to operate in PPE and this needs to be accounted for in planning our return to elective activity. The opportunity to test equipment in a simulated environment was beneficial. Ethical approval Not required Funding None Declaration of Competing Interest None declared