PAPRs for Respiratory Protection

Personal Protective Equipment (PPE) is an essential element of health care worker safety, protecting against various occupational hazards. Powered Air-Purifying Respirators (PAPRs) are an important type of protective gear that plays a critical role in maintaining respiratory health and safety in different work environments. 

A recent NETEC webinar, “PPE from A to Z: PAPRs for Respiratory Protection,” offers health care workers a guide to multiple types of PAPRs, including use and maintenance, and how PAPRs fit into a health care respiratory protection program. Watch the webinar. 

PAPRs as Part of a Respiratory Protection Program (RPP) 

An institution’s respiratory protection program is typically overseen by infection prevention departments, although they may also involve safety, occupational health, or other emergency management roles depending on the organization’s size. The key elements of respiratory protection programs include risk assessments, health assessments, which are required regardless of the need for fit testing, as well as education and training for personnel, and record keeping.  

OSHA Compliance 

The Occupational Safety and Health Administration (OSHA) mandates comprehensive training on PAPR usage, including hands-on demonstrations covering essential topics outlined in the Respiratory Protection Program (RPP) Toolkit.  

Topics Outlined in the OSHA RPP Toolkit: 

• Why the respirator is necessary (including when it must be worn)  
• Why proper fit, usage, and maintenance is crucial to its effectiveness  
• The limitations and capabilities of the respirator 
• Hands-on demonstration of how to inspect, put on, remove, use, and check the seal of the respirator  
• What the procedures are for storage and maintenance  
• How to recognize medical signs or symptoms that limit or prevent the safe, effective use of respirators  
• The general requirements of the OSHA Respiratory Protection standard  
• How to identify and react to respirator malfunctions  
• How to use the respirator in emergencies (e.g., chemical release) if appropriate 

While OSHA specifies the content, employers have flexibility in the delivery method. 

Resources and toolkits are available to assist institutions in developing their respiratory protection programs. There are several educational tools (including slide presentations, posters, and flyers) listed in the “References, Resources, and Tools” section on page 36. You may use these materials during your annual training and as needed year-round to make sure that employees are up to date on their knowledge of respiratory protection and its proper use. However, you must ensure that respirator users are fully trained on the specific risks, programs, and procedures at your hospital; can correctly put on and take off their respirators; and can recognize when their respirator needs to be repaired or replaced.  

Risk assessment is emphasized as a crucial aspect of RPP, encompassing not only special pathogens and biological hazards but also chemical and radiation risks. Different situations may require different types of respiratory protection, and staff should be educated on when to use each type appropriately. It’s important to understand the differences between protection for chemical, biological, and radiological hazards and ensure staff are trained accordingly. Post-event considerations such as disinfection also need to be addressed.  

Resources to assist healthcare institutions in developing effective respiratory protection programs tailored to their specific needs:  

• https://www.cdc.gov/niosh/docs/2015-117/default.html 
• https://www.cdc.gov/long-term-care-facilities/media/pdfs/viral-respiratory-pathogens-toolkit-508.pdf
• https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/respiratory-protection/

PAPR Filter Selection and Maintenance 

Selecting the right filters for PAPRs involves careful consideration of the chemicals and hazardous substances present in the work environment. Resources including the Emergency Response Guidebook from the Department of Transportation and a downloadable guide from 3M offer valuable insights into filter selection and maintenance. Additionally, the CDC’s National Institute for Occupational Safety and Health (NIOSH) provides a searchable Certified Equipment List to help identify suitable respirators for specific types of protection, including those for Chemical, Biological, Radiological, and Nuclear (CBRN) hazards. Adhering to OSHA requirements and manufacturer recommendations ensures timely filter changes, thereby optimizing respiratory protection. 

OSHA requires a conservative approach to filter maintenance that is defined at your facility. While these are typically based upon the End-of-Service-Life Indicator (ESLI), there is not one for infectious particles. According to OSHA regulations, “If there is no ESLI appropriate for conditions in the employer’s workplace, the employer implements a change schedule for canisters and cartridges that is based on objective information or data that will ensure that canisters and cartridges are changed before the end of their service life. The employer shall describe in the respirator program the information and data relied upon and the basis for the canister and cartridge change schedule and the basis for reliance on the data.” 

According to the manufacturers of the types of PAPR/CAPR’s discussed in the webinar, the flow alarm or light indicates when the filters must be changed. Changing filters more frequently than manufacturer recommendations may be done at the discretion of your facility in conversation with infection prevention, clinical engineering, and other partners. How often the PAPR is being used may also play a role in the frequency of changing the filters.    

PAPR Selection for Specific Settings 

The suitability of PAPR models varies based on the demands of specific workplace settings. For instance, in mobile environments like Emergency Medical Services (EMS) and ambulance care, selecting PAPRs tailored to mobility is crucial. 

PAPRs for EMS and Ambulance Care 

Transportation introduces additional wear considerations for choosing a PAPR, including confined spaces, prolonged sitting or leaning over patients, and communication challenges due to PAPR noise levels and compatibility with radios. Doffing considerations may include doing so in unfamiliar or confined settings, the potential need for assistance or tools, and the need for plans for handling reusable and disposable contaminated equipment and supplies. Careful consideration of these factors, among others, ensures the effective implementation of PAPRs in healthcare settings. 

Understanding the nuances of PAPR use in settings such as operating rooms and biocontainment units requires careful evaluation of ventilation mechanisms and contamination risks. 

PAPRs in Operating Rooms 

The CDC acknowledges that studies on the use of PAPRs in operating rooms are ongoing, however, PAPRs may be an alternative for operating room staff who cannot pass a fit test with an N95 respirator. The PAPR should vent under the shroud in which exhalation gases vent underneath the gown. Ensure you can wear the PAPR shroud in this fashion (under the gown) by checking the manufacturer’s instructions. PAPRs venting to the rear of the PAPR wearer likely provide less contamination to the surgical field. PAPRs venting to the front may contaminate the surgical field.  

For PAPRs used in operating rooms, we suggest the following approach:  

• Identify a NIOSH-approved filtering facepiece respirator (e.g., N95) for which you successfully passed a fit test.  
• If that is not possible, choose a PAPR model capable of venting under the gown. First, check the PAPR manufacturer’s instructions to verify they permit such use for that particular model. In addition, direct the PAPR blower/exhaust away from the sterile field.  
• The Association for Peri-Operative Registered Nurses issued guidance on “3 Interventions When Using a Powered Air-Purifying Respirator in the OR.”  

AORN Recommendations for PAPRs in Operating Rooms 

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.  

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.  

PAPRs for Source Control 

Most PAPR products were developed before source control was noted as an issue (pre-pandemic), so they don’t have specific source control features. Some have shrouds you can tuck into the suit, essentially allowing all exit air to travel out away from your breathing zone. In most cases, it would be wise to wear a surgical mask when source control is a consideration. The obvious challenge with this option is not being able to see expressions or read lips.  

If a PAPR is worn in the care of immune-compromised patients, your Infection Prevention and Employee Health professionals may advise other strategies that may include employee screening, immunizations, or testing. 

In several studies, PAPRs have been found to be as effective as face masks in reducing outward particle spread, but it is important to be aware of how and where exhaled air exits a PAPR hood, helmet, or shroud. For those respiratory illnesses spread predominantly by a droplet pathway, the passive exhalation under a gown, coverall, hood, or shroud is likely to decrease droplet spread but does not completely rule out aerosols (droplet nuclei).  

PAPR Studies: 

• Howard, R. A., Lathrop, G. W., & Powell, N. (2020). Sterile field contamination from powered air-purifying respirators (PAPRs) versus contamination from surgical masks. American journal of infection control, 48(2), 153-156.   
• Myers, W., Ajewole, S., Xu, S., Yorio, P., Hornbeck, A., & Zhuang, Z. (2022). Laboratory assessment of bacterial contamination of a sterile environment when using respirators not traditionally used in a sterile field environment. Infection Control & Hospital Epidemiology, 43(12), 1867-1872.  

Caring for Your PAPR 

PAPR Disinfection and Cleaning 

Proper maintenance and cleaning procedures are vital for extending the lifespan of PAPRs and ensuring their effectiveness. Following CDC guidelines for cleaning and disinfection (CDC, https://www.cdc.gov/niosh/npptl/cleaning.html, Accessed 2024), along with adhering to manufacturer recommendations, is essential. Considerations for high-risk environments and disposable components underscore the importance of meticulous decontamination practices. 

The process used and the components included in the decontamination process depend on the PAPR model, the exposure or contamination risk, and the other protective or PPE devices used. Disinfection should be thoughtful and meet the wet time for the disinfectant you are using. The process should reflect the manufacturer’s recommendation. You may need a stepwise process and identified decontamination personnel on your team to conduct the stepwise process and move equipment from dirty to clean/ready-to-use.  

When used in high-risk environments, such as the care of Ebola patients, some facilities chose to dispose of the corrugated tubing that connects the hood to the blower motor rather than attempting to clean and decontaminate it.  

Exploring your facility’s options for other types of wipes and cross-checking them with the Instructions for Use (IFU) may yield a more convenient disinfection method.  

Storage Conditions for PAPRs 

PAPRs and other PPE components require certain temperature and humidity considerations for storage. Because of the materials they are made of, the need for dry filtration material, and the lifespan of batteries, PAPR and related PPE should be kept in a temperature and humidity-controlled environment. For example, a garage without HVAC controls would not be appropriate. 

PPE Expiration 

It is impossible to fully know the risks associated with using expired PPE. NIOSH-NPPTL researchers looked at expired respirators (NIOSH, https://www.cdc.gov/niosh/media/pdfs/2024/11/ppe-case-p2020-0111-aggregated-stockpile-study-03252020-508.pdf, Accessed 2025) but their study did not include PAPRs or PAPR filters. 

Of the systems reviewed in the webinar, there are differences in the shelf life of elements from system to system. 

MAXAIR: 

• Around a 4-year service life for their Li-Ion batteries   
• Filters: hoods have built-in filters and are single use  
• Shrouds and cuffs use a filter that can be reused, however, this depends on the type of use and hospital policy. If reusing, it is recommended to change the filter every 6-12 months or when the yellow light comes on indicating the filter is loaded and requires changing.  The shelf-life (Maxair, https://maxair-systems.com/images/PDFS/TB-Shelf-Life-0412040-Rev-D.pdf, Accessed 2024) of unused filters is 5 years from the date of manufacture, which is coded into the lot number. 

ILC Dover: 

• The rechargeable batteries last around 8 hours per charge, with 500 charge/discharge cycles  
• Lithium-Ion Batteries have a 10-year shelf life  
• Alkaline batteries (5 D-cell batteries) last around10 hours 
• The filters will have an expiration date on them  

Gown Considerations for Hazmat Decontamination 

For more information on selecting a gown for hazmat decontamination, watch the NETEC webinar “PPE from A to Z: Exploring the Latest Standards and Regulations for Health Care Personnel,” which provides updates to the standards for liquid barrier protection of PPE in health care facilities and links to a downloadable one-page guide for health care personnel to reference when selecting a gown. 

Respirators with Exhalation Valves  

Exhalation valves exist primarily for breathing comfort in high-dust environments; health care is not typically a high-dust particle environment. While they were used during the pandemic to address the shortage of typical health care respirators, the CDC does not recommend the use of a respirator with an exhalation valve (CDC, https://www.cdc.gov/niosh/npptl/respirators/exhalationvalve/default.html, Accessed 2024) in certain health care situations, including but not limited to operating rooms, because the valve may allow contaminants to escape and reach others.  

Eye Protection 

Eye protection is part of standard precautions and is recommended in most biocontainment care situations. The use of eye protection should be based on a risk assessment that accounts for the reasonable anticipation of facial exposure. OSHA requirements state that masks, in combination with eye protection devices, such as glasses with solid side shields, goggles, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials (OPIM) may be generated and eye, nose, or mouth contamination can be reasonably anticipated.  

There is not currently a NIOSH or OSHA-certified eye protection product for blood and OPIM. In 2021, new guidance was created for the selection, care, and use of these items along with how they should be tested and marked: ANSI/ISEA Z87.62-2021. 

Respirators in the Ambulatory Clinic Setting 

Work with your Infection Preventionist, Safety Office, Occupational Health team, or Public Health Department to do a risk assessment based on your patient population. They will want to consider what tasks staff will be performing, how close contact needs to be, the duration of close contact, and what other controls are in place to protect staff and the workplace. These hazard assessments are a required part of a Respiratory Protection Program.   

Respirators and EMS 

The teams on the BST Consortium use a variety of PAPR units: 

• 3M Versaflo 600 
• 3M AirMate 
• 3M Breatheasy 
• ILC Dover Sentinel XP 

We have confirmed that the 3M Breatheasy will continue to be supported. The original text of this post stated that it had been discontinued.

Health care professionals should understand the use of Powered Air-Purifying Respirators (PAPRs) as part of their institution’s Respiratory Protection Programs, including the importance of complying with regulatory standards, receiving thorough training, and conducting tailored risk assessments. By focusing on key aspects, such as PAPR selection and maintenance, and following manufacturer recommendations and CDC guidelines for filter selection, maintenance, and disinfection, health care institutions can enhance the safety and resilience of their workforce, ensuring optimal patient care amidst evolving occupational hazards. 

Disclaimer 

The content presented in the webinar and this blog post about Powered Air-Purifying Respirators (PAPRs) is intended for educational purposes only. NETEC does not endorse or promote any specific brand or manufacturer of PAPRs. The information provided is meant to offer general guidance and knowledge about PAPRs and their use in health care settings. Conduct your own research and consult with appropriate experts or regulatory bodies when considering the selection or purchase of PAPRs for your specific needs. Any references to particular brands or products are purely for illustrative purposes and should not be interpreted as an endorsement by NETEC. We strive to provide unbiased and impartial information to support health care professionals in making informed decisions regarding infection prevention and control.