3 Interventions When Using a Powered Air-Purifying Respirator in the OR

Publish Date: September 11, 2019

What do you do when a patient with active tuberculosis requires an urgent and specialized surgical procedure that only one surgeon in your organization can perform and that surgeon has grown a beard, negating the facial seal of his N95 respirator?

This was a question AORN perioperative practice specialist Julie Cahn, DNP, RN, CNOR, RN-BC, ACNS-BC, CNS-CP, recently posed during an educational webinar hosted by NIOSH in honor of N95 day on Sept. 6, the 100th Respiratory Protection Awareness Week from Sept. 3–6.

To address the challenge of a perioperative team member not being able to wear an N95 respirator during care of a perioperative patient that requires airborne precautions, Cahn said the first step is to work with an interdisciplinary team to determine the best course of action by assessing these questions:

  • Is the procedure necessary at that time or if it can be rescheduled when the patient is no longer infectious?
  • Why can’t the person wear an N95 respirator? Is the issue related to facial features or facial hair or is it because a fit test was not yet performed this year?
  • Is the person that is unable to wear a surgical N95 respirator critical to the procedure or can that person can be safely replaced by an equally qualified individual who can wear a surgical N95 respirator?

Safe Use of PAPRs in the Surgical Setting

“When an interdisciplinary team determines that a PAPR [Powered Air-Purifying Respirator] is necessary during care of a perioperative patient, interventions to protect the sterile field and surgical wound site from airborne contamination should be implemented,” Cahn said.

She outlined three interventions to prevent sterile field contamination when a PAPR must be used in the OR:

  1. Determine the Type of PAPR That May Be Worn

    There are different types of PAPRs—the hood style PAPR hangs down lower over the wearer’s body versus the loose-fitting style PAPR that is fitted over the face. The exhalation of respiration from the wearer exits each device differently. The manufacturer’s instructions for use should be consulted to determine if a hood style PAPR may be worn under a sterile surgical gown, which may reduce contamination of the sterile field.

  2. Direct PAPR Exhaust and Reconfigure the Room Set-Up

    The PAPR blower is attached to a belt worn at the waist and exhausts air. The blower exhaust should be directed away from the sterile field. The perioperative team member that is wearing the PAPR may need to stand in a different location, to reduce the risk of PAPR exhaust blowing onto the sterile field. Alternatively, it may be necessary to move the sterile field out of the direction of the blower exhaust depending on the room configuration.

  3. Protect the Sterile Field
  4. Protecting the sterile field from the PAPR blower exhaust and the exhalated air from the wearer is important. One way to protect the sterile field from PAPR exhaust is to partially cover the portion of the sterile field that is not in immediate use with a sterile drape or sterile surgical towels, this will protect airborne contaminants from setting on the sterile field.

    “Surgical helmet systems, also known as hoods, used typically during orthopedic total joint procedures should NOT be used as respiratory protection devices,” Cahn added.

    She also cautioned that all respiratory protection (ie, surgical N95) should be used as a SECOND line of defense against surgical smoke exposure, with the first line of defense being surgical smoke evacuation.

Changes for PAPRs Coming Soon

Both surgical N95 respirators and PAPRs must be approved by the National Institute for Occupational Safety and Health (NIOSH). The National Personal Protective Technology Laboratory (NAPPTL) has been working to modify testing and approval of PAPRs for the health care setting because PAPRs have become more widely applied in health care settings.

Perioperative nurses looking to the evidence for guidance when a PAPR is absolutely necessary in their practice setting can look to three AORN guidelines that address this method of respiratory protection, including: The Guideline for Sterile Technique, The Guideline for Transmission-Based Precautions, and the Guideline for Surgical Smoke Safety.

Additional Resources

Stay current with PAPR developments and safety practices advised by NAPPTL and NIOSH.

Find infographic resources from the CDC for education about respiratory protection.


Free Resources for Members

Guideline Essentials: Get quick tips and tricks on airborne precautions, protecting the sterile field, and design and maintenance of the OR through Guideline Essentials' Quick Views on:


AORN Journal CNE Articles

Clinical Issues—September 2019 (1.5 FREE CHs)