COVID-19: Aerosol Generating Procedures?

Healthcare professionals worldwide are concerned about exposure to COVID-19 at work (nosocomial infection). How can we operate safely during this pandemic and minimise risk to colleagues and patients? 

Key points:

  • Transmission of COVID-19 is via aerosol or droplet spread, this can be direct or indirect via contaminated objects and surfaces (See the list of aerosol generating procedures below)

  • Local Personal Protective Equipment (PPE) guidance can vary across specialties depending on the risk of aerosol and droplet exposure, even if the procedure is not aerosol generating

  • A 2-pronged approach of selecting the appropriate PPE. and “donning and doffing” (wearing and removing) it after use will ensure that staff and patients are safe from COVID-19 spread

What is an Aerosol Generating Procedure?
Aerosol-generating procedures (AGP) are procedures that stimulate coughing and promote the generation of aerosols

Evidence available on aerosol generating procedures and transmission of infection are predominantly cohort studies on SARS (SARS-CoV)(1)
This has helped inform the infection control procedures in Asia (e.g. Hong Kong and Singapore)(2)
Although it is thought that this advice is applicable to COVID-19, care should be taken when extrapolating and interpreting findings. Therefore healthcare workers should continue to check for updates as more epidemiological evidence of COVID-19 emerges.


Aerosol generating procedures:
Source: From Public Health England, UK: COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.0

·       Tracheotomy/tracheostomy procedures

·       Intubation, extubation and related procedures

·       Open suctioning

·       Bronchoscopy

·       Surgery using high-speed devices (e.g. drills)

·       Manual ventilation

·       Non-invasive ventilation (NIV), Bi-level Positive Airway Pressure (BiPAP), Continuous Positive Airway Pressure ventilation (CPAP)

·       High-frequency oscillating ventilation (HFOV)

·       High-flow Nasal Oxygen (HFNO)

·       Induction of sputum

ENT Surgery:

ENT UK: Updates on Working in a COVID-19 Pandemic (ENT UK Guidance updated on MedShr Open on 25 March 2020)


  1. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. Plops One. 2012;7(4):e35797. doi:10.1371/journal.pone.0035797

  2. Cheng, V., Wong, S., Chen, J., Yip, C., Chuang, V., Tsang, O., Yuen, K. (n.d.). Escalating infection control response to the rapidly evolving epidemiology of the Coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in Hong Kong. Infection Control & Hospital Epidemiology, 1-24. doi:10.1017/ice.2020.58

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