疫情防护|【ANESTHESIOLOGY】COVID-19个人防护装备

翻译：苗 猫      排版：丹妮  

ABStract

Clinicians who care for patients infected with coronavirus disease 2019 (COVID-19) must wear a full suite of personal protective equipment, including an N95 mask or powered air purifying respirator, eye protection, a fluid-impermeable gown, and gloves. This combination of personal protective equipment may cause increased work of breathing, reduced field of vision, muffled speech, difficulty hearing, and heat stress. These effects are not caused by individual weakness; they are normal and expected reactions that any person will have when exposed to an unusual environment. The physiologic and psychologic challenges imposed by personal protective equipment may have multiple causes, but immediate countermeasures and long-term mitigation strategies can help to improve a clinician’s ability to provide care. Ultimately, a systematic approach to the design and integration of personal protective equipment is needed to improve the safety of patients and clinicians.

护理2019年冠状病毒病（COVID-19）感染患者的临床医生必须穿戴全套个人防护装备，包括N95面罩或电动空气净化呼吸器、护目镜、液体不渗透长袍和手套。这种个人防护装备的组合可能会导致呼吸工作增加、视野缩小、言语低沉、听力困难和热应激。这些影响不是由个人弱点造成的；它们是任何人暴露在异常环境中时的正常和预期反应。个人防护装备带来的生理和心理挑战可能有多种原因，但立即采取对策和长期缓解策略有助于提高临床医生提供护理的能力。最终，需要采用系统的方法来设计和整合个人防护设备，以提高患者和临床医生的安全性。

Clinicians around the world use personal protective equipment while caring for patients affected by the coronavirus disease 2019 (COVID-19) pandemic. Physicians of all specialties perform aerosol-generating procedures (including tracheal intubation and extubation), administer treatments that generate aerosols (e.g., bilevel positive airway pressure ventilation and high-flow nasal cannulas), or must simply stand within two meters of an infectious patient. Personal protective equipment required for the care of these patients includes an N95 mask with a face shield or powered air-purifying respirator, a gown, and gloves. This combination of personal protective equipment causes increased work of breathing, reduced field of vision, reduced tactile sensation, and heat stress.1–4 Additional problems include ill-fitting equipment and shortages that result in constant changes in the type and availability of equipment that healthcare professionals must use. Each of these challenges has the potential to impair a clinician’ s ability to care for his or her patients.

世界各地的临床医生在护理受2019冠状病毒病(COVID-19)大流行影响的患者时使用个人防护设备。所有专业的医生执行产生气溶胶的程序(包括气管插管和拔管)，实施产生气溶胶的治疗(例如，两级正压通气和高流量鼻插管)，或者必须站在感染患者两米以内。护理这些患者所需的个人防护装备包括带有面罩或动力空气净化呼吸器的N95口罩、长袍和手套。这种个人防护装备的组合会增加呼吸工作，缩小视野，减少触觉和热应激。1-4其他问题包括设备不合适和短缺，导致医疗专业人员必须使用的设备类型和可用性不断变化。这些挑战中的每一个都有可能损害临床医生照顾他或她的病人的能力。

In the past, medical equipment was designed with the expectation that the user will adapt his or her workflow to the device. Instead, the device should be designed to accommodate the needs of the user. Advances in human factors engineering lead to equipment design that will enhance, rather than impair performance. Although a single piece of equipment (e.g., an N95 mask) may cause only a minor degradation in performance, multiple items used in combination have additive effects which may significantly impair a clinician’ s ability to provide care.5 The authors have personally experienced this effect before the current pandemic but dismissed it as a mildly unpleasant, short-term problem. The COVID-19 pandemic requires that clinicians make continuous use of personal protective equipment for longer periods of time, exacerbating its effects on human performance. There is a paucity of information on the effects of prolonged use of the personal protective equipment required to care for COVID-19 patients, but at least one study has concluded that personal protective equipment produces negative effects on both the physical and mental health of healthcare workers.4

在过去，医疗设备的设计期望用户调整他或她的工作流程以适应设备。相反，设备的设计应该适应用户的需求。人因工程学的进步导致了设备设计的提高，而不是降低了性能。虽然单件设备(如N95口罩)可能只会导致轻微的性能下降，但组合使用多个项目会产生累加效应，这可能会严重削弱临床医生提供护理的能力。5作者在当前的大流行之前亲身经历过这种影响，但认为这是一个轻微的令人不快的短期问题而不屑一顾。新冠肺炎大流行要求临床医生在更长时间内持续使用个人防护装备，加剧了其对人类表现的影响。关于长时间使用护理新冠肺炎患者所需的个人防护装备的影响的信息很少，但至少有一项研究得出结论，个人防护装备对医护人员的身心健康都会产生负面影响。4

The diverse array of personal protective equipment worn by healthcare workers varies by location and availability and may also change over time. This lack of standardization can prevent clinicians from developing proficiency in its use and may negatively affect their ability to provide care.6 One possible advancement would be for health care systems, the government (e.g., National Institute for Occupational Safety and Health), and organizations with expertise to align and insist on higher and universal manufacturer standards for design, fit, and performance, which would allow for preemptive universal training, possibly translating to improved clinician safety and performance. This review will discuss how personal protective equipment can impair performance and propose immediate and long-term solutions for wearable, functional, and comfortable personal protective equipment in the patient care environment.

医护人员穿戴的各式各样的个人防护装备因地点和可用性的不同而不同，也可能随着时间的推移而变化。这种缺乏标准化可能会阻碍临床医生熟练地使用它，并可能对他们提供护理的能力产生负面影响。6一个可能的进步是医疗保健系统、政府(例如，国家职业安全与健康研究所)和具有专业知识的组织协调并坚持更高和通用的制造商设计、适配和性能标准，这将允许先发制人的普遍培训，可能转化为提高临床医生的安全性和绩效。这篇综述将讨论个人防护设备如何影响性能，并为患者护理环境中的可穿戴、功能性和舒适性个人防护设备提出即时和长期的解决方案。

Human performance: impact and countermeasures人类绩效:影响和对策

When wearing personal protective equipment, factors such as thermal stress, limitations on hearing and vision, and restriction of movement exacerbate physical and attentional fatigue. The stressors placed on healthcare professionals through their work environment and the added burden of wearing personal protective equipment are cumulative.7 The “T ask-T axon-T ask” method can be used to develop a predictive model of how physiologic and psychologic stressors can interact to impair a practitioner’ s ability to function in the clinical environment.7 This model assumes that each task uses a measurable set of skills taxons, and environmental stressors cause a decrement in each skill by a measurable amount.7 The decrease in performance can be predicted by rating the impact of the stressor on each skill, assigning each skill a proportion related to its importance to the task, then summing the total.7 For example, the T ask-T axon-T ask method can be used to show that physical fatigue, impacting motor skills, is additive to sleep deprivation, impairing cognition. Figure 1 uses this methodology to illustrate how impairment caused by wearing personal protective equipment is cumulative.

穿戴个人防护装备时，热应力、听力和视力限制以及运动受限等因素会加剧身体和注意力、疲劳。通过工作环境和穿戴个人防护设备的额外负担给医疗保健专业人员带来的压力是累积的。7 “T ask-T axon-T ask”方法可用于开发生理和心理压力源如何产生的预测模型相互作用以削弱从业者在临床环境中发挥作用的能力。7 该模型假设每项任务都使用一组可测量的技能分类单元，并且环境压力因素会导致每项技能降低可测量的数量。7 表现的下降可能通过对压力源对每项技能的影响进行评级，为每项技能分配与其对任务的重要性相关的比例，然后求和总数来预测。7 例如，可以使用 T ask-T axon-T ask 方法来显示身体疲劳会影响运动技能，会加重睡眠不足，损害认知。图 1 使用这种方法来说明佩戴个人防护设备造成的损伤是如何累积的。

图1所示。为了完成插管，临床医生需要认知、视觉和运动技能。穿戴个人防护装备可能会进一步削弱这三项技能。因此，减轻任何领域的损害都可以提高性能。7 .基于任务-分类-任务（Task-Taxon-Task）(T3)方法

Respiratory Effects呼吸系统的影响

The N95 mask protects the wearer from droplets or aerosol that contains infectious agents (e.g., Mycobacterium tuberculosis, severe acute respiratory syndrome coronavirus 2). It is defined as a negative pressure respirator because the pressure inside the mask is lower than ambient pressure during inspiration, which increases work of breathing. An N95 mask increases inspiratory flow resistance by 126%, increases expiratory flow resistance by 122%, and decreases the volume of air exchanged by 37%.1 Dead-space carbon dioxide is increased and dead-space oxygen is decreased.8 Interim guidance from U.S. Centers for Disease Control and Prevention currently recommends that if exposure to bodily fluids is anticipated, a face shield should be worn and the respirator should be covered with a surgical mask to facilitate extended use. This technique increases the resistance to inhalation and exhalation.9 Humidity from exhaled air accumulates in an N95 mask over time, further increasing the work of breathing. The effect of full-face respirators is similar to that of N95 masks.10 Increased resistance to breathing is a physiologic stressor9 and can cause dyspnea, fatigue of the respiratory muscles, and changes in lung volumes and ventilation.11 A person who is unfamiliar with this sensation may respond with either hypo- or hyperventilation.12 These physiologic stressors, even in physically fit individuals, can lead to “‘hypoxia-like’ incidents characterized by short periods of confusion and cognitive impairment. ”13

N95口罩可保护佩戴者免受含有传染病(如结核分枝杆菌、严重急性呼吸综合征冠状病毒2)的飞沫或气雾剂的伤害。它被定义为负压呼吸器，因为在吸气时，面罩内的压力低于周围的压力，这会增加呼吸功。N95口罩的吸气阻力增加了126%，呼气阻力增加了122%，空气交换量减少了37%。1死腔二氧化碳增加，死腔氧气减少。8美国疾病控制和预防中心目前的临时指南建议，如果预计暴露在体液中，应该戴上面罩，并用外科口罩覆盖呼吸器，以便于延长使用时间。这项技术增加了吸气和呼气的阻力。9随着时间的推移，呼出的空气中的湿度会累积在N95面罩中，进一步增加呼吸功。10呼吸阻力增加是一种生理压力，可导致呼吸困难、呼吸肌肉疲劳、肺容量和通气量改变。11不熟悉这种感觉的人可能会出现呼吸不足或过度通气的反应。12这些生理压力，即使是身体健康的人，也可能导致“类缺氧”事件，其特征是短暂的混乱和认知障碍。13I

Ill-fitting or uncomfortable industrial respirators have been shown to cause psychologic stress, especially in workers with claustrophobia or anxiety .14 The increased work of breathing from an N95 mask may cause anxiety in some individuals. Clinicians with asthma may experience an anxiety related dyspnea.15 This same anxiety can trigger a positive feedback cycle of hyperventilation and hyperventilation that causes an increased sensation of dyspnea.16 Half-facepiece respirators can cause more anxiety than N95 respirators in some healthcare workers.17 In spite of this, many practitioners prefer half-facepiece respirators for prolonged wear, because they have an expiratory valve that mitigates the associated increased work of breathing.18

不合适或不舒服的工业呼吸器已被证明会造成心理压力，特别是对患有幽闭恐惧症或焦虑症的工人。14增加使用N95口罩呼吸的工作量可能会导致某些人焦虑。患有哮喘的临床医生可能会经历与焦虑相关的呼吸困难。15同样的焦虑会引发过度换气和过度换气的正反馈循环，导致呼吸困难的感觉增加。16在一些医护人员中，半面式呼吸器可能比N95呼吸器引起更多的焦虑。17尽管如此，许多从业者更喜欢长时间佩戴半面式呼吸器，因为它们有一个呼气阀，可以减轻相关增加的呼吸功。18

All clinicians should be aware of the potential for hyperventilation or hypoventilation while wearing a respirator and may need to consciously control the depth or rate of breathing. Clinicians should be aware of the common symptoms of hypoventilation, which include anxiety and shortness of breath, and of hyperventilation, which include light-headedness and tingling fingers. U.S. Air Force Aerospace Physiologists teach high altitude operators to regulate breathing rate and depth by deliberately speaking out loud in long sentences. This forces a person to breathe at a normalized rate and depth, as hyperventilation is nearly impossible when talking. T eaching healthcare workers to focus on taking slow , regular breaths using their diaphragm as the predominant respiratory muscle can also help to alleviate dysfunctional breathing.19 Anecdotal reports from our colleagues suggest that powered air-purifying respirators may be more comfortable, particularly if a clinician is performing a physically demanding task.

所有临床医生都应该意识到佩戴呼吸器时可能会出现过度换气或换气不足的情况，并可能需要有意识地控制呼吸深度或呼吸速率。临床医生应该意识到换气不足的常见症状，包括焦虑和呼吸短促，以及换气过度的症状，包括头晕和手指刺痛。美国空军航空航天生理学家教导高空操作员通过故意用长句大声说话来调节呼吸频率和深度。这迫使一个人以正常的呼吸速度和深度呼吸，因为说话时过度换气几乎是不可能的。指导医护人员专注于使用横隔膜作为主要呼吸肌进行缓慢、有规律的呼吸，也有助于缓解呼吸功能障碍。19我们同事的轶事报告表明，电动空气净化呼吸器可能会更舒适，特别是当临床医生正在执行一项对身体要求很高的任务时。Tight-fitting respirators can deform and stretch the skin, causing discomfort and eventually pressure injury . Absorbent foam wound dressing material (e.g., Mepilex Lite, Mölnlycke Corp., Sweden) has been reported to reduce the risk of injury and to improve comfort in patients who are required to wear tight-fitting masks for noninvasive ventilation.20After applying this material and before entering a patient care environment, the clinician should undergo a fit check to ensure that the respirator maintains a proper seal.

紧贴的呼吸器会使皮肤变形和拉伸，导致不适，最终导致压力性损伤。据报道，吸水性泡沫创面敷料材料(例如，瑞典门利克公司的Meppeex Lite)可降低受伤风险，并改善需要佩戴紧身口罩进行非侵入性通气的患者的舒适性。20在使用这种材料之后，在进入病人护理环境之前，临床医生应该进行合适的检查，以确保呼吸器保持适当的密封。

Vision restrictions视力受限

Personal protective equipment can impair vision by reducing field of view and field of regard. Field of view is the width of the visual angle that can be viewed instantaneously within the visual field. Field of regard is the total area that can be seen when moving the head, eyes, and body .21 Field of view is reduced by the way that the head is positioned in the protective equipment and field of regard is reduced by the limited range of motion from side to side. In one study , the field of view was reduced in all of the 12 military combat eye protection devices evaluated.22 Similar vision restrictions are almost certainly created by much of the personal protective equipment employed in healthcare, and especially by powered air-purifying respirators. People use peripheral vision to orient themselves in space relative to the view they are focusing on. A person who has impaired peripheral vision may compensate with an altered posture and gait, increasing the likelihood of falls. Plastic face shields can become fogged or scratched and may also distort vision, further decreasing visual acuity and making procedures more difficult.23

个人防护装备会缩小视野和视场，从而损害视力。视场是可以在视场内即时查看的视角的宽度。视场是指移动头部、眼睛和身体时可以看到的总面积。21视场因头部位于防护设备中的方式而减小，视场因左右移动的有限范围而减小。在一项研究中，评估的所有12种军事作战眼睛保护设备的视野都缩小了。22几乎可以肯定，医疗保健中使用的大部分个人保护设备都会造成类似的视力限制，特别是电动空气净化呼吸器。人们使用边缘视觉来定位自己在空间中相对于他们所关注的视线的方向。周边视力受损的人可能会通过改变姿势和步态来弥补，从而增加跌倒的可能性。塑料面罩可能会起雾或擦伤，还可能扭曲视力，进一步降低视力，使手术变得更加困难。23

The most effective countermeasures for restricted vision include changes to the environment that facilitate situation awareness. Personal protective equipment does not appear to affect a clinician’s ability to intubate using direct laryngoscopy or through a laryngeal mask airway . If, however, a fiberoptic bronchoscope is required and a video monitor is unavailable, it may be difficult use an optical eyepiece.24 Some countermeasures that improve a pilot’ s ability to function in restricted vision situations may also be applicable to the clinician. When possible, the most critical equipment should be arranged so that it is in the clinician’ s field of view . Clinicians should remember to turn their heads and look left and right periodically to monitor objects that are not seen due to reduced peripheral vision. Because the field of regard is reduced, clinicians should be trained to understand that their vision will be limited. Clinicians may need to turn their head slowly , however, to avoid becoming dizzy , especially because they also may be experiencing heat retention. Moving the head in only one axis at a time (e.g., up and down or left and right) may help to avoid disorientation. Smooth, deliberate movements will help the clinician to maintain balance using the vestibular system of the inner ear when visual cues are decreased.

对视力受限最有效的对策包括改变环境，以促进对情况的认识。个人防护设备似乎不会影响临床医生使用直接喉镜或通过喉罩气道插管的能力。然而，如果需要光纤支气管镜，而视频监视器不可用，则可能难以使用光学目镜。24提高飞行员在受限视力情况下工作能力的一些对策也可能适用于临床医生。在可能的情况下，最关键的设备应该安排在临床医生的视野内。临床医生应该记得定期转过头来左右看，以监测由于周边视力降低而看不见的物体。因为关注的领域缩小了，临床医生应该接受培训，让他们明白他们的视野会受到限制。然而，临床医生可能需要慢慢转过头来避免头晕，特别是因为他们可能也经历了发热。一次仅沿一个轴移动头部(例如，上下或左右)可以帮助避免方向混乱。当视觉线索减少时，平稳、慎重的动作将有助于临床医生利用内耳前庭系统保持平衡。

As new personal protective equipment is developed, its impact on breathing, vision, hearing, physical movement, and anxiety should be considered during design and certification, particularly if the device is to be widely used. Readily available, inexpensive respirators may be developed that allow delivery of oxygen to the clinician25 and measurements of inspired and expired Po2 and partial pressure of carbon dioxide that could be monitored by a safety officer.13 Personnel who chronically hyperventilate while wearing a respirator, such as those individuals with asthma, may benefit from a mask that can be adjusted to allow for partial rebreathing when necessary .26

随着新的个人防护设备的开发，在设计和认证时应考虑其对呼吸、视觉、听力、身体运动和焦虑的影响，特别是如果该设备要广泛使用的话。可以开发出容易获得、价格低廉的呼吸器，它可以将氧气输送到临床医生25，并测量吸入和呼出的PO2以及二氧化碳分压，这可以由安全官员进行监测。13长期戴着呼吸器呼吸过度的人员，例如那些哮喘患者，可以从一种面罩中受益，这种面罩可以在必要时进行调整，允许部分再呼吸。26

Impaired Communication沟通障碍

Respirators such as N95 face masks and powered air purifying respirators can muffle speech, making communication difficult or impossible.27,28 Clinicians should therefore look directly at the person to whom they are speaking, speak slowly and distinctly , and plan to repeat critical information.29 Using a colleague’ s name at the beginning of a conversation may help to attract his or her attention. It is essential to verify critical communication (e.g., drug doses). Closed loop communication with verbal readbacks are therefore especially important in this environment. Because of the aforementioned vision restrictions, it may be difficult or impossible to see a coworker’s gestures or nonverbal communication, further emphasizing the importance of closed-loop communication.30 The suite of personal protective equipment used during the current pandemic has also made it difficult to identify or distinguish healthcare professionals from each other. One potential solution is for each clinician to write his or her name and title in bold letters on 3-inch tape placed over the front and back of the uniform; others have taped a photograph onto a visible part of his or her gown.31

N95口罩和电动空气净化口罩等呼吸器会使言语变得模糊，使交流变得困难或不可能。27,28因此，临床医生应该直视与他们交谈的人，缓慢而清晰地说话，并计划重复关键信息。在谈话开始时使用同事的名字可能有助于吸引他或她的注意力。必须验证关键通信（如：药物剂量）。因此，在这种环境下，通过口头回读进行闭环通信尤为重要。由于上述视觉限制，可能很难或不可能看到同事的手势或非语言交流，这进一步强调了闭环交流的重要性。30在当前大流行期间使用的一套个人防护设备也使得医疗专业人员之间难以识别或区分。一种可能的解决办法是，每位临床医生都要在制服前后的3英寸胶带上用粗体字母写下自己的姓名和头衔；其他人则将照片贴在他或她的长袍的可见部分。31

Decreased Manual Dexterity手部灵活性下降

Clinicians will experience a decrease in manual dexterity caused by movement restrictions or the decreased tactile feedback provided by multiple layers of gloves.32 One study comparing intravenous with intraosseous vascular access with the provider wearing personal protective equipment and a mannequin with or without personal protective equipment concluded that vascular access was established more rapidly by the intraosseous route (14 vs. 46 s).33 Intravenous access took 90 s longer than intraosseous access in a simulated disaster scenario in which participants wore personal protective equipment.3 Data from the military corroborate that when wearing chemical protective clothing, it takes more time to finish a task.34 These studies highlight the fact that some procedures requiring a high degree of manual dexterity can take longer and might be more difficult when wearing personal protective equipment.

临床医生将体验到由于运动限制或多层手套提供的触觉反馈减少而导致的手动灵活性下降。32一项研究比较了穿戴个人防护装备的提供者和穿着或不穿个人防护装备的人体模型的静脉和骨内血管通路，得出结论是，通过骨内途径建立血管通路更快(14比46秒)。33在参与者穿戴个人防护装备的模拟灾难场景中，静脉通路比骨内通路所需的时间长90秒。3来自军方的数据证实了这一点：在模拟的灾难场景中，参与者穿着个人防护装备，静脉途径比骨内途径更快地建立血管途径(14秒对46秒)。33在模拟的灾难场景中，参与者穿着个人防护装备，静脉途径比骨内途径多花90秒的时间。完成一项任务需要更多的时间。34这些研究突出了这样一个事实，即一些需要高度手工灵巧的程序可能需要更长的时间，而且在穿戴个人防护装备时可能会更加困难。

Clinicians should expect that procedures such as endotracheal intubation and vascular access may take longer than expected. If help is needed, assistants will need to don personal protective equipment before entering the patient care area, so clinicians should call for help earlier, especially if a patient is developing respiratory failure and may need an emergency intubation. For intraoperative procedures, clinicians should also set a lower threshold for establishing vascular access, securing the airway , or calling for extra equipment that may be needed during surgery . Although this does not appear to have been studied in healthcare professionals, practicing procedures using double gloves before performing them on an infected patient may help clinicians to compensate for any reduction in manual dexterity.

临床医生应该预料到，气管插管和血管通路等程序可能需要比预期更长的时间。如果需要帮助，助手在进入患者护理区域之前需要穿上个人防护装备，因此临床医生应该更早地呼叫帮助，特别是如果患者正在发生呼吸衰竭，可能需要紧急插管。对于术中操作，临床医生也应该设定一个较低的门槛来确定血管通道，保护气道，或呼吁在手术期间可能需要的额外设备。尽管这似乎没有在医疗保健专业人员中得到研究，但在对感染患者实施手术前使用双手套进行练习可能会帮助临床医生弥补手工灵活性的任何下降。

physical and Mental Fatigue身心疲惫

Personal protective equipment imposes restrictions on movement and increases the difficulty of tasks requiring physical exertion, such as chest compressions during cardiopulmonary resuscitation. In addition to a decrease in the percentage of adequate compressions, rescuers exhibited an increase in heart rate, arterial blood pressure, and subjective fatigue.35 T olerance to aerobic exercise is decreased when a person is not adequately hydrated; this effect exacerbates the progressive dehydration that occurs during exercise.36 Full-face, negative pressure respirators can impair performance on cognitive tasks,37 and it seems reasonable to assume that other respirators (such as half-face respirators) may have similar effects. Mental fatigue is also exacerbated by personal protective equipment, and the task-taxon-task model suggests that aggregate effects of stress can worsen cognitive impairment.7 This mental fatigue can present as anxiety , which impairs working memory as a result of processing of extraneous information.38

个人防护装备限制了行动，增加了需要体力消耗的任务的难度，如心肺复苏期间的胸部按压。除了适当按压的百分比下降外，救援人员还表现出心率、动脉血压和主观疲劳感的增加。35当一个人水分不足时，有氧运动的耐受力降低；这种影响加剧了运动过程中发生的渐进性脱水。36全脸负压呼吸器可能会损害认知任务的表现，37而且似乎有理由认为其他呼吸器(如半脸呼吸器)也可能有类似的效果。个人防护装备也会加剧脑力疲劳，任务-分类-任务模型表明，压力的综合效应会加重认知障碍。7这种脑力疲劳可能表现为焦虑，这种焦虑会由于处理无关信息而损害工作记忆。

Specific countermeasures to mitigate physical and mental stress include adequate hydration and personal protective equipment that minimizes heat accumulation and enables physiologic regulation of body temperature. Healthcare professionals who wear impermeable protective equipment should drink at least 0.7 l per hour to mitigate the effects of dehydration39 and remove sweaters or warm-up jackets to prevent overheating. When clinically feasible, dividing strenuous tasks may decrease the fatigue associated with wearing protective equipment. Powered air purifying respirators do not seem to offer a significant improvement in respiratory function over N95 masks but may be more comfortable, particularly if a clinician is performing a physically demanding task for an extended period of time. T eam leaders should ensure that clinicians receive adequate breaks, nutrition, and sleep whenever feasible. Clinicians can reduce the strain on prospective memory by making a list of critical tasks that must be performed in the future (e.g., antibiotic administration, redosing heparin during vascular procedures) and by using a cognitive aid during critical and off-nominal events.40

缓解身体和精神压力的具体对策包括充足的水分和个人防护装备，以最大限度地减少热量积累，并能够对体温进行生理调节。身穿不透水防护装备的医护人员应至少每小时喝0.7升水以减轻脱水的影响39并脱去毛衣或热身夹克以防止过热。在临床可行的情况下，划分繁重的任务可能会减少穿戴防护装备带来的疲劳。与N95口罩相比，电动空气净化呼吸器似乎不能显著改善呼吸功能，但可能会更舒适，特别是当临床医生长时间执行体力要求较高的任务时。领导应确保临床医生在可能的情况下获得足够的休息、营养和睡眠。临床医生可以通过列出未来必须执行的关键任务(例如，抗生素给药、血管手术期间重新添加肝素)以及在关键和非名义事件期间使用认知辅助来减轻预期记忆的压力。40

Thermoregulation温度调节

Surgical masks, N95 masks, and powered air-purifying respirators must comply with National Institute for Occupational Safety and Health regulations. Similar regulations apply to head covers, isolation gowns, fluid impermeable gowns, and gloves. Each of these regulations focuses primarily on how the personal protective equipment is used. Personal protective equipment is designed to be impermeable to fluids such as sweat, trapping hot air between the clinician’s clothing and body , and limits heat transfer by radiation and convection. Obstructions to airflow , such as fitted arm or leg cuffs, can reduce or eliminate a path for hot air to escape or cool air to enter. This results in a micro-climate of hot, humid air that inhibits the evaporation of moisture such as sweat. W earing extensive personal protective equipment, particularly in a warm environment (such as a pediatric operating room), may therefore cause heat stress in healthcare workers.41

外科口罩、N95口罩和电动空气净化呼吸器必须符合美国国家职业安全与健康研究所的规定。类似的规定适用于头套、隔离服、流体不渗透服和手套。这些法规中的每一条都主要关注如何使用个人防护设备。个人防护设备设计为不渗透液体，如汗液，在临床医生的衣服和身体之间捕获热空气，并限制辐射和对流的热传递。气流障碍物，如安装的手臂或腿部袖口，可减少或消除热空气逸出或冷空气进入的路径。这导致了高温潮湿空气的微气候，抑制了水分（如汗水）的蒸发。因此，佩戴广泛的个人防护设备，特别是在温暖的环境中（如儿科手术室），可能会导致医护人员产生热应激。41

Clinicians can mitigate some of the effects of heat stress by minimizing layers of clothing (e.g., surgical scrubs) under the personal protective equipment. Prescription eyeglasses can be secured to the face so that they do not slip as a result of perspiration,42 possibly with an elastic band. A clinician who is sweating should resist the temptation to adjust his or her eyeglasses while wearing personal protective equipment. If the patient is not at risk for hypothermia, the room should be cooled. Loose-fitting and tight-fitting half-face powered air purifying respirators ameliorate exercise-induced increases in facial skin temperature when compared to an N95 mask. This can lead to a hazardous situation in which the wearer may feel a normal face and head temperature while his or her core temperature is increasing.43 Clinicians should consider measuring their temperature regularly and ensure that they are well hydrated if required to wear personal protective equipment for an extended period of time.4

临床医生可以通过尽量减少个人防护装备下的衣物(例如外科擦洗)的层数来减轻热应激的影响。处方眼镜可以固定在脸上，这样它们就不会因为出汗而滑倒，42可能是用橡皮筋。出汗的临床医生应该抵制在穿着个人防护装备时调整眼镜的诱惑。如果病人没有体温过低的危险，房间应该降温。与N95口罩相比，宽松和紧凑的半脸动力空气净化呼吸器可以缓解运动引起的面部皮肤温度升高。这可能会导致危险的情况，佩戴者可能会感到面部和头部温度正常，而他或她的核心温度正在上升。43临床医生应该考虑定期测量他们的体温，并确保他们在需要长时间穿戴个人防护装备时水分充足。4

Difficulty of Donning and Doffing personal protective Equipment个人防护装备穿脱困难

Donning and doffing personal protective equipment is more difficult to perform than many clinicians expect, and failure to remove personal protective equipment correctly represents a significant safety hazard. Self-assessment of proficiency is a poor predictor of a clinician’ s ability to correctly don and doff personal protective equipment.44 Self-contamination can be common for clinicians who are unfamiliar with this task. In one study , for example, protocol deviations prior to training occurred in 27% of healthcare workers doffing personal protective equipment.45 Another study found that 79% of healthcare workers contaminated themselves in at least one area while doffing personal protective equipment.6 The authors of this study concluded that the errors with the highest risk were those related to hand hygiene and mishandled or compromised personal protective equipment (especially exposed hands and wrists).46 In less experienced personnel, the potential for contamination is even greater. Only 41% of medical students reported receiving personal protective equipment training, and none had received training to a demonstrated level of proficiency .47 The same study showed that 93% of trainees had one or more lapses in technique during simulation and 44% contaminated their skin with a fluorescent lotion.47 This suggests that strategies to improve donning and doffing of personal protective equipment should be implemented before the need for use. Potential strategies include procedural changes, optimization of the environment, and training.

穿戴和脱下个人防护设备比许多临床医生预期的更难操作，未能正确移除个人防护设备意味着严重的安全隐患。熟练程度的自我评估不能很好地预测临床医生正确穿戴和脱下个人防护装备的能力。44对于不熟悉这项任务的临床医生来说，自我污染很常见。例如，在一项研究中，27%的脱下个人防护装备的医护人员在培训前出现协议偏差。45另一项研究发现，79%的医护人员在脱下个人防护装备时，至少在一个方面污染了自己。6本研究的作者得出结论，风险最高的错误是与手部卫生和个人防护设备（尤其是暴露的手和手腕）操作不当或损坏有关的错误。46在经验较少的人员中，污染的可能性更大。只有41%的医学生报告说接受了个人防护装备培训，没有人接受过证明熟练程度的培训。47同一项研究表明，93%的学员在培训期间有一次或多次技术失误44%的人用荧光乳液污染了他们的皮肤。47这表明，在需要使用个人防护装备之前，应实施改进个人防护装备穿戴和脱下的策略。潜在策略包括程序变更、环境优化和培训。

表1.可能有助于佩戴个人防护装备的临床医生的对策摘要

Improved procedures and workspace design can improve the safety of personal protective equipment and reduce the risk of contamination. Clear, detailed instructions and the use of visual cognitive aids can help to improve the safety of donning and doffing personal protective equipment.48 Personnel who are developing donning and doffing procedures should evaluate potential failure modes and design procedures to include an extra margin of safety .48Workspace design should include mirrors (to allow the clinician to see possible contamination sites), handrails, prominent disposal bins, readily available gloves and hand sanitizer, and clear demarcation of “clean” and “dirty” zones.49 A trained safety coach instructing the clinician step by step how to don and doff the equipment has been shown to help ease healthcare worker anxiety and decrease errors resulting in self contamination. A checklist may assist the safety coach.40

改进的程序和工作空间设计可以提高个人防护设备的安全性，降低污染风险。清晰、详细的说明和视觉认知辅助工具的使用有助于提高穿戴和脱下个人防护装备的安全性。48制定穿脱程序的人员应评估潜在故障模式和设计程序，以包括额外的安全余量（理解：多余准备？）。工作空间的设计应包括镜子（允许临床医生看到可能的污染场所）、扶手、突出的处理箱、现成的手套和洗手液，以及“干净”和“脏（污染）”区域的清晰划分。49经培训的安全教练指导临床医生如何一步一步地穿上和脱下设备，这有助于缓解医护人员的焦虑，减少导致自我污染的错误。检查表可能有助于安全教练。40

Training personnel in the setting in which they will work may be of benefit. Subjects can recall information more effectively in the environment in which it was originally learned,50 especially if that workspace contains signage and design cues to facilitate high level performance.51 It may also be beneficial to train healthcare workers to perform procedures and manage critical events while wearing personal protective equipment. This could be done, for example, outside an empty operating room or in the anteroom to an intensive care unit room. A simulation center can also be configured to emulate these spaces. This physical space would not only give environmental cues but also emulate the restricted space in these areas. Another measure to improve donning and doffing of personal protective equipment is to focus on error-prone steps46 and to practice multiple times. The philosophy to repeat training “not until you get it right, but until you never get it wrong” may be applicable in this setting and should be employed by clinical leaders who are responsible for reserving time to train for what may be perceived as infrequently used skills.

在工作环境中培训人员可能会有所裨益。受试者可以在最初学习信息的环境中更有效地回忆信息，50特别是如果该工作区包含标牌和设计提示，以促进高水平的表现。51培训医护人员在穿戴个人防护装备的同时执行程序和管理关键事件也可能是有益的。例如，可以在空手术室外或在重症监护病房的前厅内进行。还可以配置模拟中心来模拟这些空间。这个物理空间不仅可以提供环境提示，还可以模拟这些区域的受限空间。另一项改进个人防护装备穿戴和脱下的措施是关注容易出错的步骤46并多次练习。重复培训的理念“直到你做对了，但直到你永远不会弄错”可能适用于这种情况，临床领导应该采用这种理念，他们负责为可能被视为不经常使用的技能预留时间进行培训。

psychologic issues: interpreting physical Discomfort as Stress心理学问题：将身体不适解释为压力

Extended use of personal protective equipment may cause discomfort from restricted movement, weight, and heat. This can increase anxiety and stress and lower tolerance for pain and discomfort.52,53 Anxiety has been shown to decrease working memory and impair performance across a wide variety of tasks54 and could conceivably exacerbate the errors that a clinician might make while donning or doffing personal protective equipment. Setting the expectation that some amount of discomfort is normal when wearing personal protective equipment may improve healthcare workers’ tolerance to it. One study found that that participants had increased tolerance to pain after reading a positive statement and concluded that the subjective threat associated with pain was mediated by the participants’ viewpoints.52 Clinicians who are required to wear personal protective equipment may benefit from counseling as to its safety and the fact that some amount of discomfort is normal (e.g., a slightly increased work of breathing while wearing an N95 mask indicates a proper seal).

长期使用个人防护设备可能会因限制移动、重量和热量而导致不适。这会增加焦虑和压力，降低对疼痛和不适的耐受性。52,53研究表明，焦虑会降低工作记忆，损害各种任务54的表现，并可能加剧临床医生在穿戴或脱下个人防护装备时可能犯的错误。设定佩戴个人防护装备时一定程度的不适感是正常的期望值，可能会提高医护人员的耐受性。一项研究发现，参与者在阅读了积极的陈述后，对疼痛的耐受性有所提高，并得出结论，与疼痛相关的主观威胁是由参与者的观点介导的。52要求佩戴个人防护装备的临床医生可能会从咨询中受益，了解其安全性以及一定程度的不适是正常的。（如：佩戴N95面罩时呼吸功稍有增加，表明密封良好）。

Teaching clinicians coping skills can also help to improve their tolerance to discomfort. A mindfulness training program developed for the United States military is designed to mitigate the stress caused by training and subsequent deployment and teaches personnel to develop attentional control and tolerance to challenging experiences such as harsh environmental conditions, anxiety , and discomfort. The program teaches specific skills that use concepts from psychotherapy to enhance resilience and enable complex decision making. United States Marines who participated in this program were found to have significantly lower physiologic markers associated with stress and an improved response to stress.55 A game-based educational program teaches deployed service members how to conduct brief interventions for their colleagues, including cognitive restructuring, breathing exercises, and muscle relaxation techniques.56 This technology has been demonstrated in the clinical environment: A mindfulness program developed to help surgeons manage burnout and fatigue was shown to improve wellbeing and executive function.57 Programs such as these are readily adaptable to the current clinical environment and could be introduced rapidly

教授临床医生应对技巧也有助于提高他们对不适的耐受性。为美国军方开发的正念训练计划旨在减轻训练和随后部署造成的压力，并教导人员培养注意力控制和对挑战性经历(如恶劣环境条件、焦虑和不适)的容忍度。该计划教授特定的技能，使用心理治疗的概念来增强韧性，并使复杂的决策成为可能。参加活动的美国海军陆战队队员在这个项目中，我们发现与压力相关的生理指标显著降低，对压力的反应也得到改善。55一个基于游戏的教育计划教部署的服务人员如何为他们的同事进行简短的干预，包括认知重建、呼吸练习和肌肉放松技术。56这项技术已经在临床环境中得到证实：一项旨在帮助外科医生管理倦怠和疲劳的正念计划被证明可以改善健康和执行功能。57个这样的项目很容易适应当前的临床环境，并且可以迅速引入。

conclusions结论

The COVID-19 pandemic reinforces the critical role that clinicians play in caring for patients and managing resources during local, regional, and global disasters. Clinicians are frequently on the front line of the response and are thus at an increased risk for infection. The personal protective equipment that is routinely used to protect clinicians imposes a variety of physiologic and psychologic stressors that may impair their performance. Modern medical personal protective equipment protects healthcare professionals but is often difficult to don and doff, is uncomfortable, and may impair a clinician’ s ability to care for his or her patients. This article offers immediate countermeasures that can help to mitigate these effects and provide some relief to clinicians who must wear personal protective equipment (table 1).

COVID-19 大流行强化了临床医生在地方、区域和全球灾难期间护理患者和管理资源的关键作用。临床医生经常站在反应的第一线，因此感染风险增加。通常用于保护临床医生的个人防护设备会产生各种生理和心理压力，可能会影响临床医生的工作表现。现代医疗个人防护设备保护医疗专业人员，但通常很难穿脱，不舒服，可能会损害临床医生照顾患者的能力。这篇文章提供了可以帮助减轻这些影响的即时对策，并为必须佩戴个人防护装备的临床医生提供了一些缓解措施（表1）。

Improving the design of personal protective equipment can help to preserve a clinician’s performance, especially in circumstances where this equipment will be worn for a prolonged period of time. Health care systems, government agencies, and experts in human performance should therefore work together to set universal standards for equipment quality , requirements, fit, and training. Although this article has described physiologic and psychologic stressors in the context of the current pandemic, the principles described are similar whenever clinicians work in an environment to which they are not accustomed. Healthcare professionals can improve patient safety and protect themselves by understanding how they are affected by physiologic and psychologic stressors and then implementing the appropriate countermeasures.

改进个人防护设备的设计有助于保持临床医生的表现，尤其是在长时间佩戴该设备的情况下。因此，医疗保健系统、政府机构和人类绩效专家应共同努力，为设备质量、要求、适配和培训制定通用标准。尽管本文在当前大流行的背景下描述了生理和心理压力源，但当临床医生在他们不习惯的环境中工作时，所描述的原则是相似的。医疗保健专业人员可以通过了解他们如何受到生理和心理压力源的影响，然后实施适当的对策来提高患者的安全性并保护自己。

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