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      Adapting re‐usable elastomeric respirators to utilise anaesthesia circuit filters using a 3D‐printed adaptor ‐ a potential alternative to address N95 shortages during the COVID‐19 pandemic

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          Summary

          The COVID‐19 pandemic has increased the demand for disposable N95 respirators. Re‐usable elastomeric respirators may provide a suitable alternative. Proprietary elastomeric respirator filters may become depleted as demand increases. An alternative may be the virus/bacterial filters used in anaesthesia circuits, if they can be adequately fitted onto the elastomeric respirators. In addition, many re‐usable elastomeric respirators do not filter exhaled breaths. If used for sterile procedures, this would also require modification. We designed a 3D‐printed adaptor that permits elastomeric respirators to interface with anaesthesia circuit filters and created a simple modification to divert exhaled breaths through the filter. We conducted a feasibility study evaluating the performance of our modified elastomeric respirators. A convenience sample of eight volunteers was recruited. Quantitative fit testing, respiratory rate and end‐tidal carbon dioxide were recorded during fit testing exercises and after 1 h of wear. All eight volunteers obtained excellent quantitative fit testing throughout the trial. The mean (SD) end‐tidal carbon dioxide was 4.5 (0.5) kPa and 4.6 (0.4) kPa at baseline and after 1 h of wear (p = 0.148). The mean (SD) respiratory rate was 17 (4) breaths.min −1 and 17 (3) breaths.min −1 at baseline and after 1 h of wear (p = 0.435). Four out of eight subjects self‐reported discomfort; two reported facial pressure, one reported exhalation resistance and one reported transient dizziness on exertion. Re‐usable elastomeric respirators to utilise anaesthesia circuit filters through a 3D‐printed adaptor may be a potential alternative to disposable N95 respirators during the COVID‐19 pandemic.

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          Coping with COVID ‐19: ventilator splitting with differential driving pressures using standard hospital equipment

          Summary The global COVID‐19 pandemic has led to a worldwide shortage of ventilators. This shortage has initiated discussions on how to support multiple patients with a single ventilator (ventilator splitting). Ventilator splitting is incompletely tested, experimental and the effects have not been fully characterised. This study investigated the effect of ventilator splitting on system variables (inspiratory pressure, flow and volume) and the possibility of different ventilation targets for each limb using only standard hospital equipment. Experiments were conducted on two test lungs with different compliances (0.02 l.cmH2O−1 and 0.04 l.cmH2O−1). The ventilator was used in both pressure and volume control modes and was set to ventilate the low compliance lungs at end‐tidal volumes of 500 ± 20 ml. A flow restrictor apparatus consisting of a Hoffman clamp and tracheal tube was connected in series to the inspiratory limb of the high compliance test lungs and the resistance modified to achieve end‐tidal volumes of 500 ± 20 ml. The restriction apparatus successfully modified the inspiratory pressure, minute ventilation and volume delivered to the high compliance test lungs in both pressure control (27.3–17.8 cmH2O, 15.2–8.0 l.min−1 and 980–499 ml, respectively) and volume control (21.0–16.7 cmH2O, 10.7–7.9 l.min−1 and 659–498 ml, respectively) ventilation modes. Ventilator splitting is not condoned by the authors. However, these experiments demonstrate the capacity to simultaneously ventilate two test lungs of different compliances, and using only standard hospital equipment, modify the delivered pressure, flow and volume in each test lung.
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            Training and Fit Testing of Health Care Personnel for Reusable Elastomeric Half-Mask Respirators Compared With Disposable N95 Respirators

            This study examines the feasibility of rapidly training and fit testing health care workers to use elastomeric half-mask respirators (EHMRs), widely used in construction and manufacturing, as an alternative to N95 respirators during periods of shortage.
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              Safety testing improvised COVID ‐19 personal protective equipment based on a modified full‐face snorkel mask

              Reported shortages of personal protective equipment (PPE) in the NHS have caused anxiety among healthcare workers 1. Several designs for improvised PPE have been circulated online and via social media. One particularly widely shared design involves a 3D printed adaptor to allow the mating of a standard anaesthetic heat and moisture exchange (HME) filter to a commercially available snorkelling mask. Thingiverse, an online repository of 3D printable files, contains at least 18 adaptor designs that users can download 2. Although one specific combination of mask, filter and HME has apparently passed fit‐testing 3, given the variation in masks, adaptors and HME filters we are concerned there are insufficient safety data to recommend general use of these devices. Websites generally contain important disclaimers that the systems have not been subjected to peer review or rigorously tested, but we remain anxious that users may attempt to wear these devices in clinical practice without proper validation. To evaluate one such design, we tested PPE based on an Omew full‐face snorkel mask purchased from Amazon 4. An adaptor from the Thingiverse website was printed on a 3D printer (Prusa i3 mk2 with standard PLA material. 1.75 nozzle, 0.15 layer height), to which we attached an Intersurgical Cleartherm‐3 HME filter (Intersurgical, Wokingham, UK). The assembled system is illustrated in Fig. 1. We subjected the system to a series of tests, firstly to check clinical applicability, and secondly to test fit. Quantitative fit‐testing was conducted using the TSI Portacount 8038 system (TSI UK, High Wycombe, UK). Figure 1 Depiction of the improvised PPE system. One user was asked to perform simulated cannulation, airway management and patient transfer while wearing the mask. After donning the mask, the user performed a successful negative‐pressure fit‐check, by manually occluding the HME filter and inhaling. Over the next 20 min of activity there was a small degree of fogging of the internal surfaces, but this did not impair vision. We measured FIO2, ETO2 and ETCO2 with essentially no changes in gas composition over the testing period (FIO2: 0.20–0.21; EtO2: 0.15–0.17 kPa; ETCO2: 3.7–4.0 kPa). The user reported minimal discomfort and noted that in this regard it was comparable to a validated reusable filtering facepiece (FFP) 3 mask. Of great concern, however, was that the mask failed the quantitative fit‐testing process despite the apparently successful fit‐check. To permit formal fit‐testing, we mounted a sampling line between the mask‐adaptor and the filter using standard breathing system parts, such that gas was sampled from within the mask without disrupting the face seals. Three attempts were made with minor modifications to the snorkel adaptor between each joint to reinforce the system. In every case the mask failed during the initial ‘normal breathing’ phase. It might be speculated that snorkel masks are simply poorly suited for this use. When submerged, a high‐pressure exists outside the mask which presses it to the face. In air there is no such gradient, so there remains only the force exerted by the head straps to hold it securely. It is not clear that they are sufficient to this task. We recognise we have tested only a single combination of adaptor and mask on a single user, but our data demonstrate that it is essential to properly fit‐test before use. It is crucially important to note that fit‐testing quantitative methods are mandatory for full‐face masks (such as this improvised system) 5; qualitative fit‐testing, using taste‐ or smell‐based substances, is not adequate. It is laudable that people are attempting to ameliorate the shortages of PPE worldwide, but we cannot recommend that staff use improvised equipment in clinical situations without fit‐testing. There may be instances in which these systems can be safely used but, as with formal PPE systems, it is clear there is no ‘one‐size fits all’, and to use these improvised designs without proper testing may present a significant hazard to staff.
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                Author and article information

                Contributors
                Role: Residentdexterliu@rcsi.ie
                Role: Occupational Therapy Assistant
                Role: Department Manager
                Role: Department Operations Manager
                Role: Consultant
                Role: Senior Occupational Safety and Health Manager
                Role: Chief of Service
                Journal
                Anaesthesia
                Anaesthesia
                10.1111/(ISSN)1365-2044
                ANAE
                Anaesthesia
                John Wiley and Sons Inc. (Hoboken )
                0003-2409
                1365-2044
                26 May 2020
                : 10.1111/anae.15108
                Affiliations
                [ 1 ] Department of Anaesthesiology and Pain Medicine United Christian Hospital Hong Kong
                [ 2 ] Department of Occupational Therapy United Christian Hospital Hong Kong
                [ 3 ] Operating Room United Christian Hospital Hong Kong
                [ 4 ] Department of Pathology United Christian Hospital Hong Kong
                [ 5 ] Occupational Safety and Health Team Hospital Authority Kowloon East Cluster Hong Kong
                Author notes
                [*] [* ] Correspondence to: D. C. Y. Liu

                Email: dexterliu@ 123456rcsi.ie

                Article
                ANAE15108
                10.1111/anae.15108
                7267584
                32348561
                f3308b59-07b9-4291-8d82-b8ba5329e84a
                © 2020 Association of Anaesthetists

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                History
                : 28 April 2020
                Page count
                Figures: 3, Tables: 1, Pages: 6, Words: 9708
                Categories
                Original Article
                Original Articles
                Custom metadata
                2.0
                corrected-proof
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.3 mode:remove_FC converted:03.06.2020

                Anesthesiology & Pain management
                covid‐19,breathing system filter,anaesthesia circuit filter,respirator,3d‐printed adaptor

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