Position statement: Recommendations on air clearance in TOE rooms during the COVID-19 pandemic

Published 18/01/2022

COVID-19 continues to circulate worldwide, at various dynamically changing rates, and with the emergence of novel strains of varying clinical consequences.

This is of direct relevance to the risk of aerosol related infection risk during transoesophageal echocardiography due to its aerosol generating nature (Hung, 2020; SCST, 2020). We have issued guidance on personal protective equipment (PPE) for transthoracic, stress and transoesophageal echocardiography (TOE) (BSE, 2020).

An additional factor to account for the provision and performance of high infection risk TOE is the provision of sufficient air flow exchanges within the TOE room before entry by staff without a FFP3 mask/equivalent respirator can occur, surface decontamination commences, following which the next study can be performed. Public Health England advice, based upon World Health Organisation advice, is that 6 full air changes be made, following which less than 1% of airborne contaminants will remain. The room used for high-risk TOE should have high-efficiency particulate air (HEPA filters) or windows that are opened. Ideally a negative pressure room should be used for high-risk cases, as this will permit faster air exchange.

COVID-19 positive patients should be considered high risk. As COVID-19 infection rates and variants vary geographically, criteria for identifying intermediate and low risk TOE patients will require local discussion. Clinical factors, local epidemiology and local infection control policy ought to identify high, intermediate, and low risk cases for COVID-19 infection. We recommend that high risk patients undergoing TOE be covered by the guidance above, whilst air clearance management for intermediate and low risk categories for COVID-19 cases undergoing TOE be decided through local policy.


  1. BSE. (2020, June). Post COVID-19 guidance | TOE. Retrieved from https://www.bsecho.org/Public/News/Articles/2020/2020-06/202005-COVID-guidance-TOE.aspx
  2. Hung, J. A. (2020). ASE Statement on the Reintroduction of Echocardiographic Services during the COVID-19 Pandemic. Am Soc Echo, 1034-1039.
  3. SCST. (2020). Retrieved from https://scst.org.uk/wp-content/uploads/2020/06/SCST-Consensus-Recommendations-for-PPE-for-Cardiology-Procedures-June-2020.pdf

BSE Council December 2021