Clinical update

Managing aerosol generating procedures in school for children with complex medical needs

Department for Education in England’s updated guidance covers aerosol generating procedures for children with a tracheostomy or respiratory difficulties

Department for Education in England’s updated guidance covers aerosol generating procedures for children with a tracheostomy or respiratory difficulties

Essential information

Children who have a tracheostomy or complex respiratory difficulties may sometimes require suctioning or other procedures to clear their airways and help them breathe.

Known as aerosol generating procedures (AGPs) because they produce airborne particles, they include non-invasive ventilation, bi-level positive airway pressure ventilation and continuous positive airway pressure ventilation.

Department for Education in England’s updated guidance covers aerosol generating procedures for children with a tracheostomy or respiratory difficulties

Child with a tracheostomy
Child with a tracheostomy. Picture: SPL

Essential information

Children who have a tracheostomy or complex respiratory difficulties may sometimes require suctioning or other procedures to clear their airways and help them breathe.

Known as aerosol generating procedures (AGPs) because they produce airborne particles, they include non-invasive ventilation, bi-level positive airway pressure ventilation and continuous positive airway pressure ventilation.

Following the outbreak of the COVID-19 pandemic and subsequent lockdown in England, all children were meant to go back to school in the autumn. But government guidance on how to manage AGPs in schools prevented some children from returning.

In a survey by the charity WellChild, 30 children were identified as being told they could not return to school, although they were well, because schools did not have the facilities or resources to comply with the rules. The number of children who were affected is thought likely to have been significantly higher.

What’s new?

In December, the Department for Education in England updated its guidance Safe Working in Education, Childcare and Children’s Social Care Settings, Including the Use of Personal Protective Equipment (PPE).

The guidance – published before the further closure of UK schools announced in early January this year - includes steps that should be taken to care for children with complex medical needs.

Specifically referring to AGPs, it says: ‘We expect children, young people and learners with complex health needs will be able to return to their education or social care setting without settings needing to make significant changes to their ways of work beyond required adherence to the system of controls.’

While ideally children should still be taken to a separate room for AGPs, in schools where this is not possible AGPs can take place in the classroom, providing anyone not involved with the procedure is at least two metres away and there is a window open for ventilation, the guidance says.

The guidance also clarifies which procedures are not identified as AGPs. These include:

  • Oral or nasal suction.
  • Administration of nebulised saline, medication or drugs.
  • Chest compressions or defibrillation.
  • Chest physiotherapy.
  • Administration of oxygen therapy.
  • Suctioning as part of a closed system circuit.
  • Nasogastric tube insertion and feeding.

How you can help your patient

This guidance is especially relevant for nurses working in the mainstream school sector as well as special schools, and alongside community children’s nurses, who support children in both types of school.

It also stresses the need for a collaborative approach between education and social care settings, families and local agencies to find solutions.

As a child’s healthcare plan and clinical protocols are largely written by nurses, with support from other professionals, nurses are integral to providing risk assessments.

This includes looking at environments and checking whether it is possible to move furniture, for example, so these procedures can be safely accommodated.

The child’s parents and the child themselves should be involved, depending on their level of cognition.

Expert comment

 Mark Whiting, consultant nurse in children's community and specialist nursing at Hertfordshire Community NHS Trust

Mark Whiting is a consultant nurse in children's community and specialist nursing at Hertfordshire Community NHS Trust

‘This is a positive step forward. Before this guidance was published there were significant numbers of children with complex healthcare needs who were struggling to get back to school, and that certainly includes those with a tracheostomy or complex respiratory difficulties.

‘It’s been difficult for families, although there are some that are understandably anxious and concerned that their child might pick up COVID-19 from others in the school, especially for those who are very vulnerable.

‘The new guidance allows for aerosol generating procedures to be performed in the child’s classroom, following appropriate risk assessments, when it is not possible to take them to another room.

‘Nurses should make sure they’re sufficiently familiar with the guidance to be able to confidently provide expert clinical reassurance to schools and parents, recognising that guidance may change as evidence evolves.’


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