Auscultating with personal protective equipment (PPE) during COVID-19 pandemic - Challenges and solutions.

Dear Editor,

Ever since the COVID-19 outbreak was reported in December 2019, the standard of precautions to be followed by healthcare workers (HCW) to avoid exposure has continuously evolved. As COVID-19 spreads via respiratory droplets and aerosols from infected person and also through contaminated fomites, wearing personal protective equipment (PPE) has become the essential method of preventing infection among HCWs across the world [1]. PPE includes items such as gloves, goggles, faceshields, N-95 masks, hoods, shoe-covers, and full body suits or gowns.

Wearing a standard PPE while providing direct care to COVID19 patients or during aerosol generating procedures involves complete covering of entire body [1,2]. However, wearing a full PPE is not without limitations like personal discomfort, claustrophobia, fogging of googles or faceshields, difficulty in communication and performing procedures [2]. One of the main limitations is the difficulty to healthcare workers carrying out auscultation using stethoscope. Since both ears are covered completely with hood of PPE suit, earpieces of stethoscope cannot be directly placed into ears. The ear piece can only be placed over PPE gown and it is difficult to auscultate this way. Creating opening in PPE is not advisable as it might breach the sterile barrier and increase the risk of transmission. Moreover, a stethoscope can also serve as a potential fomite which can facilitate cross contamination between patients.

Auscultation with stethoscope is a very critical part of clinical assessment which is used in respiratory, cardiovascular and obstetric examinations. COVID-19 being a primary respiratory disease needs frequent respiratory system examination, especially auscultation for assessment of clinical status throughout the hospital course. Auscultation may also be needed after intubation to check air entry, cardiovascular auscultation, obstetric examination to hear fetal heart sounds and emergency conditions like pneumothorax to take quick management decisions. Inability to perform auscultation can significantly affect assessment and hence management and outcome of patients with COVID-19.

This issue can be addressed by using innovative equipment instead of traditional stethoscopes. Creating ear pouches on either side of PPE hood using the fabric of surgical masks to allow access to earpieces of stethoscopes have been tried in resource limited setup but its safety has not been established [3]. Digital/electronic stethoscopes are a novel alternative, where a ‘receiver’ portion of the stethoscope remotely connects to a smartphone app and plays the sound picked by ‘receiver’ via the phone’s speakers [4,5]. Various models of digital stethoscope are available for commercial use including iStethoscope Pro (Peter Bentley, UK), SensiCardiac (Stone Three Healthcare, South Africa), One Digital Stethoscope (Thinklabs, USA), The Steth IO (Steth IO, USA) and Eko Core (Eko Devices, USA) [5]. Another option would be to use portable hand held ultrasound which uses ultrasonic waves to detect abnormality on the striking surface which can be transmitted, recorded and played in a smartphone [5]. Innovations could preclude the necessity for old fashioned auscultation using stethoscope during COVID-19 pandemic. While health facilities should procure these alternative instruments for clinical use in COVID-19 patients and to ensure safety of HCWs, further innovation and resourcefulness of the healthcare community is the need of the hour to address this problem.

Contributors

TA and VS conceived the concept, reviewed the literature and drafted the manuscript. All authors have approved the final version of the manuscript. TA shall act as guarantor of the paper

Declaration of Competing Interest

None.

Funding

Nil.