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柳叶刀-呼吸病学：通风不良的空间中的小飞沫气溶胶与SARS-CoV-2传播

2020-12-24 柳叶刀 柳叶刀TheLancet

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导语：医疗卫生机构应该考虑尽量避免公共空间通风不良。

  导语：医疗卫生机构应该考虑尽量避免公共空间通风不良。

 

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　　《柳叶刀-呼吸病学》（The Lancet Respiratory Medicine）近日发表评论，文章通过测量飞沫的粒径分布、传播距离和速度以及不同通风水平的空气传播时间，对咳嗽和讲话产生的飞沫进行了分析，研究证实改善公共空间的通风条件可以稀释并清除潜在的传染性气溶胶。

 

　　全球的医疗卫生机构都在寻找有效措施，防止严重急性呼吸综合征冠状病毒2（SARS-CoV-2）的社区传播。虽然关于社区传播影响因素的数据不多，但普遍认为SARS-CoV-2的主要传播途径是感染者的呼吸飞沫。[1]已经证实，讲话和咳嗽时产生的微小飞沫（直径从亚微米级到接近10微米）含有病毒颗粒，[2]而且病毒可以在气溶胶里存活3小时并保持感染性。[3]飞沫可以通过空气（气溶胶）进入气道而直接传播，[4]也可以通过被污染的手部接触而间接传播。传播方式可能会对感染始发于上呼吸道还是下呼吸道产生影响，从而影响疾病进展的严重程度。[5]需要注意的是，SARS-CoV-2传播的剂量-反应关系仍不明确，尤其是在病毒的气溶胶传播方面。但是，在通风不良的空间内，再加上低湿度和高温因素，[6]含有少量病毒的气溶胶可能会逐步达到传播剂量。

　　　
　　为了更好地了解呼吸道飞沫传播并探索可能的预防措施，我们通过测量飞沫的粒径分布、传播距离和速度以及不同通风水平的空气传播时间，对咳嗽和讲话产生的飞沫进行了分析。

　
　　我们使用喷雾飞沫测量系统（英国Malvern公司的Malvern Spraytec）进行了激光衍射测量，以确定单次咳嗽和讲话产生的呼吸飞沫粒径分布。在一名健康志愿者的单次咳嗽中，我们发现了两种不同类型的飞沫，分别是直径100-1000微米的大飞沫和直径1-10微米的小飞沫，其中小飞沫更为普遍（Figure 1）。在讲话过程中，我们只发现了小飞沫（Figure 1）。虽然既往研究已发现大飞沫与咳嗽有特别的联系，[4]但在本研究中，我们观察到两种大小的飞沫都可以在咳嗽中产生。

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 Figure1: appendix p 1
　

　　然后，我们使用SprayScan（美国伊利诺伊州Glendale Heights公司的喷雾系统）激光片追踪飞沫，通过拍摄飞沫对激光的散射[7]来确定飞沫的速度和轨迹。观察结果显示，大飞沫迅速落到地面（Figure 2）。我们发现，虽然咳嗽开始时飞沫的速度为2-7米/秒不等，但肉眼可见的大飞沫（直径通常为500微米左右）不会传播太远，在重力的作用下，它们的运动轨迹呈向下弯曲状，并在1秒内迅速落到地面。这一观察结果可以用重力（F=mg；F是力，m是质量，g是加速度）和空气阻力（F=6πηRU；η是空气粘度，R是飞沫半径，U是下落速度）的相互作用来解释，同理也可以得出，当飞沫产生于距地面160厘米的高度时（即讲话或咳嗽的平均高度），半径通常为5微米的小飞沫需要9分钟才能到达地面。这些小飞沫尤其令人感兴趣，因为它们与SARS-CoV-2的气溶胶传播有关。[8]我们还研究了鼻腔产生的飞沫，发现在正常的鼻呼吸时产生的飞沫水平（2.6个飞沫，标准差为1.7）与背景噪声无差异（2.3个飞沫，标准差为1.5）。我们发现，喷嚏产生的飞沫同时来源于口腔和鼻腔，且大部分非常大，不能持久存在。

Figure 2: appendix p 2

　  
　　同样的激光片用于研究咳嗽产生的小飞沫在空气中漂浮的时间。我们使用Medspray（荷兰恩斯赫德的一家公司）特别设计的喷嘴，将一定数量的小飞沫分散到空气中，模拟咳嗽产生的效果。通过喷嘴均匀分散平均直径为5微米的飞沫后，我们使用一种能检测飞沫产生光照的算法，分析了通过悬浮在实验装置中央的固定激光片的飞沫数量。我们在三个通风水平不同的房间里重复实验，分别是：无通风，只有机械通风，机械通风并打开一个入口门和一扇小窗户（Figure 3）。在通风状况最好的房间，30秒后的飞沫数量减半；而在无通风的房间，飞沫减半的时间大约需要5分钟。这一结果与空气阻力计算结果一致，即在咳嗽或讲话的平均高度产生的5微米飞沫到达地面的时间为9分钟。在通风不良的房间，飞沫数量减半的时间为1.4分钟。

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Figure 3: appendix p 3

 　
　　虽然我们只研究了健康志愿者，没有直接研究COVID-19感染者或会产生含病毒气溶胶飞沫的患者，但本研究发现的飞沫粒径分布以及持久性数据，确实对于戴口罩预防病毒传播的要求有提示作用。本研究中的小飞沫气溶胶传播只有使用高性能的口罩才能防止；传统的外科口罩只能阻挡30%的吸入性气溶胶小飞沫；[9]但对呼出气体的阻挡效果更好。[10]
另外，我们发现气溶胶在空气中悬浮的时间很长，这一结果会影响通过智能手机接触者追踪程序所监测到的个体时间和空间接触数据的可靠性。在这类应用程序的开发和落地中，需要考虑这些研究发现。

 　
　　本研究表明，良好通风可以极大降低呼吸飞沫在空气中的悬浮时间。这一发现有重要意义，因为尽管采取了物理隔离的预防措施，诸如公共交通工具和疗养院等通风不良且人员密集的场所仍存在病毒传播的案例。在这类通风不良的空间中，小呼吸飞沫的持续存在可能会导致SARS-CoV-2的传播。我们的发现证实，改善公共空间的通风条件可以稀释并清除潜在的传染性气溶胶。为了抑制SARS-CoV-2的传播，我们认为医疗卫生机构应该考虑尽量避免公共空间通风不良。这一启示对于医院环境也很重要，因为在医院中，由于咳嗽和医学治疗产生气溶胶以及与COVID-19患者密切接触都很常见。

E
ND

G Aernout Somsen, Cees van Rijn, Stefan Kooij, Reinout A Bem, *Daniel Bonn

d.bonn@uva.nl

Cardiology Centers of the Netherlands, Amsterdam, Netherlands (GAS); Van der Waals-Zeeman Institute, Institute of Physics, University of Amsterdam, Amsterdam, 1098XH, Netherlands (CvR, SK, DB); and Department of Pediatric Intensive Care, Emma Children’s Hospital, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands (RAB)

RAB’s institution has previously received minor funding for invited lectures from AbbVie. All other authors declare no competing interests. 

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    2021-10-30 ms306040998833292

    #呼吸病学#

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    2021-01-30 hukaixun

    #SARS-CoV#

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1688054, encodeId=01e01688054d3, content=<a href='/topic/show?id=577a396e60f' target=_blank style='color:#2F92EE;'>#呼吸病学#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39676, encryptionId=577a396e60f, topicName=呼吸病学)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f99a28444895, createdName=ms306040998833292, createdTime=Sat Oct 30 11:11:09 CST 2021, time=2021-10-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1663436, encodeId=52601663436a9, content=<a href='/topic/show?id=2653396e53b' target=_blank style='color:#2F92EE;'>#呼吸病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39675, encryptionId=2653396e53b, topicName=呼吸病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed5525610796, createdName=ms9833124466084992, createdTime=Sun Mar 07 18:11:09 CST 2021, time=2021-03-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1937979, encodeId=deed193e97996, content=<a href='/topic/show?id=02de15902d3' target=_blank style='color:#2F92EE;'>#SARS-CoV#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=15902, encryptionId=02de15902d3, topicName=SARS-CoV)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6ab940, createdName=hukaixun, createdTime=Sat Jan 30 00:11:09 CST 2021, time=2021-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1745114, encodeId=5a1e1e4511472, content=<a href='/topic/show?id=b45994933bd' target=_blank style='color:#2F92EE;'>#通风#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94933, encryptionId=b45994933bd, topicName=通风)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=医者仁心, createdTime=Fri Oct 15 12:11:09 CST 2021, time=2021-10-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1321245, encodeId=87821321245bd, content=<a href='/topic/show?id=ac0d159007f' target=_blank style='color:#2F92EE;'>#SARS#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=17, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=15900, encryptionId=ac0d159007f, topicName=SARS)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Thu Dec 24 06:11:09 CST 2020, time=2020-12-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517663, encodeId=c374151e66346, content=<a href='/topic/show?id=af406381462' target=_blank style='color:#2F92EE;'>#气溶胶#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=63814, encryptionId=af406381462, topicName=气溶胶)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c83e11099687, createdName=huagfeg, createdTime=Thu Dec 24 06:11:09 CST 2020, time=2020-12-24, status=1, ipAttribution=)]
    2021-10-15 医者仁心

    #通风#

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1688054, encodeId=01e01688054d3, content=<a href='/topic/show?id=577a396e60f' target=_blank style='color:#2F92EE;'>#呼吸病学#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39676, encryptionId=577a396e60f, topicName=呼吸病学)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f99a28444895, createdName=ms306040998833292, createdTime=Sat Oct 30 11:11:09 CST 2021, time=2021-10-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1663436, encodeId=52601663436a9, content=<a href='/topic/show?id=2653396e53b' target=_blank style='color:#2F92EE;'>#呼吸病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39675, encryptionId=2653396e53b, topicName=呼吸病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed5525610796, createdName=ms9833124466084992, createdTime=Sun Mar 07 18:11:09 CST 2021, time=2021-03-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1937979, encodeId=deed193e97996, content=<a href='/topic/show?id=02de15902d3' target=_blank style='color:#2F92EE;'>#SARS-CoV#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=15902, encryptionId=02de15902d3, topicName=SARS-CoV)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6ab940, createdName=hukaixun, createdTime=Sat Jan 30 00:11:09 CST 2021, time=2021-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1745114, encodeId=5a1e1e4511472, content=<a href='/topic/show?id=b45994933bd' target=_blank style='color:#2F92EE;'>#通风#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94933, encryptionId=b45994933bd, topicName=通风)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=医者仁心, createdTime=Fri Oct 15 12:11:09 CST 2021, time=2021-10-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1321245, encodeId=87821321245bd, content=<a href='/topic/show?id=ac0d159007f' target=_blank style='color:#2F92EE;'>#SARS#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=17, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=15900, encryptionId=ac0d159007f, topicName=SARS)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Thu Dec 24 06:11:09 CST 2020, time=2020-12-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517663, encodeId=c374151e66346, content=<a href='/topic/show?id=af406381462' target=_blank style='color:#2F92EE;'>#气溶胶#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=63814, encryptionId=af406381462, topicName=气溶胶)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c83e11099687, createdName=huagfeg, createdTime=Thu Dec 24 06:11:09 CST 2020, time=2020-12-24, status=1, ipAttribution=)]
    2020-12-24 小刀医生

    #SARS#

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1688054, encodeId=01e01688054d3, content=<a href='/topic/show?id=577a396e60f' target=_blank style='color:#2F92EE;'>#呼吸病学#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39676, encryptionId=577a396e60f, topicName=呼吸病学)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f99a28444895, createdName=ms306040998833292, createdTime=Sat Oct 30 11:11:09 CST 2021, time=2021-10-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1663436, encodeId=52601663436a9, content=<a href='/topic/show?id=2653396e53b' target=_blank style='color:#2F92EE;'>#呼吸病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39675, encryptionId=2653396e53b, topicName=呼吸病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed5525610796, createdName=ms9833124466084992, createdTime=Sun Mar 07 18:11:09 CST 2021, time=2021-03-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1937979, encodeId=deed193e97996, content=<a href='/topic/show?id=02de15902d3' target=_blank style='color:#2F92EE;'>#SARS-CoV#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=15902, encryptionId=02de15902d3, topicName=SARS-CoV)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6ab940, createdName=hukaixun, createdTime=Sat Jan 30 00:11:09 CST 2021, time=2021-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1745114, encodeId=5a1e1e4511472, content=<a href='/topic/show?id=b45994933bd' target=_blank style='color:#2F92EE;'>#通风#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94933, encryptionId=b45994933bd, topicName=通风)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=医者仁心, createdTime=Fri Oct 15 12:11:09 CST 2021, time=2021-10-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1321245, encodeId=87821321245bd, content=<a href='/topic/show?id=ac0d159007f' target=_blank style='color:#2F92EE;'>#SARS#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=17, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=15900, encryptionId=ac0d159007f, topicName=SARS)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Thu Dec 24 06:11:09 CST 2020, time=2020-12-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517663, encodeId=c374151e66346, content=<a href='/topic/show?id=af406381462' target=_blank style='color:#2F92EE;'>#气溶胶#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=63814, encryptionId=af406381462, topicName=气溶胶)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c83e11099687, createdName=huagfeg, createdTime=Thu Dec 24 06:11:09 CST 2020, time=2020-12-24, status=1, ipAttribution=)]
    2020-12-24 huagfeg

    #气溶胶#

    0