50 AJTCCM VOL. 31 NO. 2 2025
EDITORIAL
Occupational inhalant exposures in the operating theatre are an
under-recognised hazard, particularly in low- to middle-income
countries (LMICs), where control measures are oen inadequate.
Healthcare professionals working in these environments are subjected
to chronic exposure to various inhalant exposures, which may aect
lung health, especially the airways, over time.
The cross-sectional study of theatre staff in Sudan by Ibrahim
et al.[1] assessed spirometric indices among 92 healthcare
professionals who routinely worked in operating theatres, including
anaesthetists, surgeons, scrub nurses and assistants. Comparison
with a matched unexposed group revealed that operating theatre
personnel had signicantly lower mean lung function indices for
forced expiratory volume in 1 second (FEV₁), forced vital capacity
(FVC), FEV₁/FVC ratio, and peak expiratory ow parameters. e
decrease in lung function was more pronounced with increasing years
of working in the operating theatre, especially among scrub nurses and
assistants, who are commonly exposed to chemical disinfectants and
surgical smoke. is is one of few studies to report on lung function
in operating theatre personnel. However, there were some limitations,
including the choice of a suitable comparison group, small sample
size, possible over-adjusting in the analysis, and lack of objective
exposure information. e study raises an important question – what
are the likely causative agents responsible for the decrements in lung
function observed in these theatre sta? Potential candidates to be
considered include waste anaesthetic gases (WAGs), surgical smoke,
cleaning agent aerosols and bio-aerosols (including non-infectious
natural rubber latex particles), or in all likelihood a combination of
these exposures.
A cross-sectional Brazilian study showed that young physicians
exposed to elevated concentrations of WAGs over a 3-year period
during their residency had significantly higher biomarkers of
DNA damage, increased micronucleus frequency, and elevated
inammatory markers (interleukin (IL) 17) compared with controls,[2]
while another study also found increased levels of IL-8.[3] Both these
proinammatory interleukins (IL-8 and IL-17) can aect the airways
and contribute to respiratory pathology and airway disease.[4] A recent
systematic review of exposure studies of halogenated anaesthetic gases
in hospitals suggested that monitoring practices for WAGs varied
considerably between countries and that there were no internationally
based exposure standards for desurane and sevourane, despite
them being commonly used.[5] Furthermore, real-time environmental
monitoring was rarely used, hampering early detection to enable risk
mitigation. It is probable that exposures can oen exceed occupational
exposure limits in operating theatres, especially those without eective
scavenging or ventilation systems, which is likely to be the case in
under-resourced settings.
Surgical smoke, generated during electrocautery and laser
procedures, may be another potential culprit. It is composed of ne
particulates, toxic organic compounds, and biological contaminants
(viable and non-viable material). However, few studies have quantied
the long-term impact of surgical smoke on lung function. A study of
perioperative theatre sta in Malaysia revealed that levels of nitrous
oxide and halogenated agents exceeded international exposure
standards, and were accompanied by increased reports of symptoms
among theatre nurses and anaesthetists.[6] The study suggested
that prolonged exposure to surgical smoke was associated with an
increased prevalence of airway symptoms, including asthma-like
symptoms (12%). However, a recent meta-analysis concluded that the
risk of exposure to surgical smoke has historically been overstated and
that there was little evidence for health risks associated with exposure
to surgical smoke.[7]
Evidence for the role of cleaning agents in causing lung function
abnormalities is perhaps more convincing. In a recent review,
Mwanga etal.[8] identied various synthetic chemical disinfectant or
cleaning agents, including aldehydes, peracetic acid and quaternary
ammonium compounds, as signicant contributors to airway disease,
including asthma and chronic obstructive pulmonary disease, in
hospital workers. In particular, symptoms of irritant-induced asthma
and lung function abnormalities have been associated with regular
use of these agents, especially in the aerosolised form. Given that
theatre assistants are oen tasked with cleaning instruments and
surfaces between procedures, their cumulative exposure is likely to
be considerable, increasing their risk of developing asthma.
In addition to these ubiquitous exposures in theatre environments,
latex aeroallergens represent a historically signicant but constantly
overlooked inhalational hazard. Powdered latex gloves, widely used
in these environments in the past, release airborne latex proteins that
are inhaled, causing immunoglobulin E-mediated sensitisation and
occupational asthma. Various studies have shown that replacement
of powdered high-protein gloves with powder-free, low-protein
or non-latex alternatives has led to a substantial decline in new
sensitisation cases and latex-induced asthma globally, especially
in high-income countries.[9] However, in many LMIC or under-
resourced settings, cost considerations mean that these gloves
continue to be used, especially in public sector health facilities,
posing a risk to theatre sta.
These various studies suggest that a constellation of inhalant
exposures in the operating theatre have the potential to cause airway
disease and pulmonary function abnormalities if unaddressed. e
heterogeneity in agent types, exposure duration and integrity of
environmental control measures makes it dicult to attribute the
decreased lung function observed in the Ibrahim study[1] to a specic
cause. Furthermore, the specic occupational exposures in this setting
were not characterised, and they were not specically correlated with
work-related respiratory symptoms or adverse lung function outcomes.
It is plausible, however, that the absence of eective control measures
in such facilities, such as active scavenging for WAGs, surgical smoke
evacuation systems, adequate general ventilation and appropriate
respiratory protective equipment, could have contributed to the
adverse lung function outcomes observed. Given the small sample
size and the cross-sectional nature of the study design, the Ibrahim
study[1] lacked the power to conduct more advanced exposure-
response analysis to identify the causative factors associated with these
lung function decits. Future longitudinal studies conducted in larger
populations of health workers and incorporating both exposure and
adverse respiratory outcomes, including work-related symptoms and
Spotlight on lung health in operating theatre sta
AJTCCM VOL. 31 NO. 2 2025 51
EDITORIAL
repeated spirometric measurements, will have greater ability to assess
deterioration over time.
Nevertheless, the ndings of Ibrahim etal.[1] and other related
studies of operating theatre environments have important implications
for occupational health surveillance and policy, especially in
LMIC healthcare institutions. Regular environmental and medical
surveillance of theatres and theatre sta should be performed to
identify prolonged high-risk exposure settings. Risk reduction
strategies, including improved ventilation, routine use of scavenging
and smoke evacuation systems, and substitution of high-risk cleaning
agents with safer alternatives, should be required in such facilities.
To achieve optimal ventilation in healthcare environments, various
international bodies have consistently proposed higher air change
rates for operating theatres, as contained in the ANSI/ASHRAE/ASHE
Standard 170 for Ventilation of Health Care Facilities. is standard
requires conventional operating theatres to have a minimum of 25 air
changes per hour (ACH) when built. While the level may fall to20
ACH for older theatres over time, it is advised that air changes should
be kept at this level through regular maintenance.[10,11] Latex exposure
that continues to exist in certain settings should be eliminated through
the procurement of non-powdered, low-protein gloves or latex-
free gloves. Training of sta in best practices for reducing airborne
exposures to chemical and bio-aerosols is also essential.
In conclusion, while it is probable that operating theatre sta are
at increased risk of adverse lung function outcomes as a result of
cumulative multiple inhalational exposures from various sources, the
attributable fraction of these causes needs further investigation in well-
designed longitudinal studies of workers in high-risk occupational
settings.
Mohamed F Jeebhay, MB ChB, DOH, MPhil (Epi), MPH
(OccMed), PhD, FCPHM (SA) Occ Med
Occupational Medicine Division, School of Public Health and
Department of Medicine, Faculty of Health Sciences, University of
Cape Town, South Africa
mohamed.jeebhay@uct.ac.za
1. Ibrahim JB, Ali IA, Mohammed MA, Ahmed IA, Musa OA. Evaluation of spirometric
lung function among healthcare professionals working in operating theatres:
Acomparative cross-sectional study. Afr J oracic Crit Care Med 2025;31(2):e2639.
https://doi.org/10.7196/AJTCCM.2025.v31i2.2639
2. Braz MG, Carvalho LIM, Chen CO, etal. High concentrations of waste anesthetic
gases induce genetic damage and inammation in physicians exposed for three years:
A cross-sectional study. Indoor Air 2020;30(4):512-520. https://doi.org/10.1111/
ina.12643
3. Chaoul MM, Braz JR, Lucio LM, Golim MA, Braz LG, Braz MG. Does occupational
exposure to anesthetic gases lead to increase of pro-inammatory cytokines? Inamm
Res 2015;64(11):939-942. https://doi.org/10.1007/s00011-015-0881-2
4. Silva MAP, Carvalho LIM, Destro MV, Braz LG, Braz MG. From indoors to outdoors:
Impact of waste anesthetic gases on occupationally exposed professionals and related
environmental hazards – a narrative review and update. Environ Toxicol Pharmacol
2025;113:104624. https://doi.org/10.1016/j.etap.2024.104624
5. Keller M, Cattaneo A, Spinazzè A, etal. Occupational exposure to halogenated
anaesthetic gases in hospitals: A systematic review of methods and techniques to assess
air concentration levels. Int J Environ Res Public Health 2022;20(1):514. https://doi.
org/10.3390/ijerph20010514
6. Fikri MR, Rahmawati TH. Health eects of surgical smoke and its associated factors
among perioperative healthcare workers in Hospital Serdang. Int J Public Health Clin
Sci 2019;6(1):131-137. https://doi.org/10.32827/ijphcs.6.1.131
7. Hurst RD, Stewart CL. Hazards of surgical smoke from electrocautery: A critical review
of the data. Am J Surg 2024;233:29-36. https://doi.org/10.1016/j.amjsurg.2024.02.017
8. Mwanga HH, Dumas O, Migueres N, le Moual N, Jeebhay MF. Airway diseases related
to the use of cleaning agents in occupational settings. J Allergy Clin Immunol Pract
2024;12(8):1974-1986. https://doi.org/10.1016/j.jaip.2024.02.036
9. LaMontagne AD, Radi S, Elder DS, Abramson MJ, Sim M. Primary prevention of
latex-related sensitisation and occupational asthma: A systematic review. Occup
Environ Med 2006;63(5):359-364. https://doi.org/10.1136/oem.2005.025221
10. American Society of Heating, Refrigerating and Air-Conditioning Engineers
(ASHRAE). Healthcare facilities. In: 2019 ASHRAE Handbook – HVAC Applications.
Chapter 9. Atlanta, Ga: ASHRAE, 2019. https://www.ashrae.org/file%20library/
technical%20resources/covid-19/i-p_a19_ch09_health_care_facilities.pdf (accessed
12 May 2025).
11. Humphreys H. Infection prevention and control considerations regarding ventilation
in acute hospitals. Infect Prev Pract 2021;3(4):100180. https://doi.org/10.1016/j.
infpip.2021.100180
Afr J Thoracic Crit Care Med 2025;31(2):e3652. https://doi.org/10.7196/AJTCCM.2025.
v31i2.3652
