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Non-invasive ventilation for COVID-19 patients isn’t linked to heightened infection risk

New research has found that the use of non-invasive breathing support to treat moderate to severe COVID-19 infection, isn’t linked to a heightened infection risk, as currently thought.

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The study, funded by the National Institute for Health Research (NIHR) and the Medical Research Council, shows the use of non-invasive breathing support, commonly known as continuous positive airways pressure (CPAP) and high-flow nasal oxygen (HFNO), produced little measurable air or surface viral contamination, and not more than simple oxygen therapy.

CPAP delivers a steady level of pressurised air and oxygen through a face mask to assist breathing; HFNO delivers oxygen at high flow rate through two small tubes in the nose. Both CPAP and HFNO have been thought to be ‘aerosol generating procedures’ which expose healthcare staff and other patients to a heightened infection rate. CPAP and HFNO have been thought to generate particles containing virus capable of contaminating the air and surfaces nearby, necessitating additional infection control precautions such as segregating patients and wearing protective gear to prevent the risk of aerosol transmission.

Researcher Professor Danny McAuley, Professor at Queen’s University Belfast and Consultant in Intensive Care Medicine at the Royal Victoria Hospital, said: “Our findings show that the non-invasive breathing support methods do not pose a higher risk of transmitting infection, which has significant implications for the management of the patients.”

"If there isn’t a higher risk of infection transmission, current practices may be over cautious measures for certain settings, for example preventing relatives visiting the sickest patients, whilst underestimating the risk in other settings, such as coughing patients with early infection on general wards.”

The research involved 30 patients with moderate to severe COVID-19 across three hospitals in the UK. The patients were divided into three groups of 10 and given either supplemental oxygen, CPAP, or HFNO to compare the amount of air and surface environmental contamination with SARS-CoV-2.

Each patient was swabbed for SARS-CoV-2 and had three air and three surface samples collected from the immediate vicinity where healthcare workers provide care. The presence of viral RNA was detected by PCR targeting two viral genes, and positive or suspected-positive samples were then cultured for any demonstration of viable virus.

Overall, 21 (70%) patients tested positive for SARS-CoV-2 by PCR nasopharyngeal swab at the time of assessment. But only 4 out of 90 (4%) air samples were PCR positive.

Neither the use of CPAP nor HFNO nor coughing were associated with significantly more environmental contamination than supplemental oxygen use. Of the total of 51 positive or suspected-positive samples by viral PCR detection, only one sample from the nasopharynx of an HFNO patient was shown as biologically viable in cell culture assay.

The study, published in Thorax, has prompted the researchers to call for a thorough reassessment of the infection control measures deployed for the non-invasive ventilation support methods.

Professor Gavin Perkins of Warwick Clinical Trials Unit at the University of Warwick said: “Infection prevention and control policies are important for protecting patients and NHS workers, but the evidence base relating to aerosol generating procedures is limited.

“Our research suggests the risks associated with CPAP and HFNO may be less than originally thought and should prompt an evidence based review of infection control practice guidelines.”

Professor McAuley added: “CPAP is being adopted into clinical care pathways for appropriate hospital admissions across all NHS hospitals. It is timely that we can now demonstrate that CPAP doesn’t put others at any higher risk when treating the patient.”

Dr Christopher Green, Consultant Physician in Infectious Diseases at University Hospitals Birmingham NHS Foundation Trust and Senior Clinical Lecturer at the University of Birmingham, said: “Our study builds on the combined work of ISARIC and the RECOVERY-RS trial, which looked at COVID-19 admissions and the use of non-invasive ventilatory support, or NIV, to treat moderate-to-severe disease.

“Although more research is needed to confirm our findings, this is the first indication that NIV care such as CPAP or HFNO may not justify their current classification of being 'aerosol-generating' procedures.

“I’d like to thank everyone involved in this work in Birmingham, with particular thanks to the patients who took part at a very difficult time for each of them, but who were still keen to support research that was focused on understanding the risks to the healthcare workers giving care to them and other patients.”

The research team included Queen’s University Belfast, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, University of Warwick, University of Liverpool and University of Edinburgh.


  1. Professor Danny McAuley is available for interview. Bids and media enquiries to
  2. Research: SARS-CoV-2 environmental contamination from hospitalised patients with COVID-19 receiving aerosol-generating procedures doi:10.1136/thoraxjnl-2021-218035
  3. The research team includes: Winslow, Rebecca; University Hospitals Birmingham NHS Foundation Trust, Department of Infectious Diseases & Tropical Medicine; The University of Manchester Division of Population Health Health Services Research and Primary Care, The Epidemiology and Public Health GroupZhou, Jie; Imperial College London, Department of Infectious DiseasesWindle, Ella; University of Birmingham College of Medical and Dental SciencesNur, Intesar; University of Birmingham College of Medical and Dental SciencesLall, Ranjit; University of Warwick Warwick Clinical Trials UnitJi, Chen; University of Warwick Warwick Clinical Trials UnitMillar, Jonathan; The University of Edinburgh The Roslin InstituteDark, Paul; NIHR Manchester Biomedical Research Centre; Northern Care Alliance NHS Group, Critical Care UnitNaisbitt, Jay; Northern Care Alliance NHS Group, Critical Care UnitSimonds, Simonds, Anita; Royal Brompton and Harefield hospitals;  Dunning, Jake; Imperial College London, Faculty of MedicineBarclay, WendyBaillie, John Kenneth; University of Edinburgh Roslin Institute, Genetics and GenomicsPerkins, Gavin; University of Warwick, Clinical Trials UnitSemple, Malcolm; NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool; Alder Hey Children's Hospital, Respiratory MedicineMcAuley, Daniel; Queen's University Belfast Wellcome-Wolfson Institute for Experimental Medicine; Royal Victoria Hospital,  Regional Intensive Care UnitGreen, Christopher; University Hospitals Birmingham NHS Foundation Trust, Department of Infectious Diseases & Tropical Medicine; University of Birmingham College of Medical and Dental Sciences; University of Birmingham, Institute of Microbiology & Infection
  4. Additional quotes for consideration: Professor Calum Semple, co-investigator and Chief Investigator of the ISARIC Coronavirus Clinical Characterisation Consortium said: "This paper adds to the evidence, that infection prevention control for COVID-19 should focus on the patient and place in terms of their infectiousness and the ventilation of their environment, rather than solely the procedures and levels of care that they receive."
  5. About NIHR: The mission of the National Institute for Health Research (NIHR) is to improve the health and wealth of the nation through research. We do this by:

    • Funding high quality, timely research that benefits the NHS, public health and social care;
    • Investing in world-class expertise, facilities and a skilled delivery workforce to translate discoveries into improved treatments and services;
    • Partnering with patients, service users, carers and communities, improving the relevance, quality and impact of our research;
    • Attracting, training and supporting the best researchers to tackle complex health and social care challenges;
    • Collaborating with other public funders, charities and industry to help shape a cohesive and globally competitive research system;
    • Funding applied global health research and training to meet the needs of the poorest people in low and middle income countries.
    • NIHR is funded by the Department of Health and Social Care. Its work in low and middle income countries is principally funded through UK Aid from the UK government.

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