New guidelines for respiratory etiquette

Cough or sneeze into elbow sleeve

Concern about several emerging health problems, including the severe acute respiratory syndrome (SARS), bioterrorism agents, and an anticipated influenza pandemic have contributed to a strengthened focus on respiratory etiquette in two revised guidelines.

Both the "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007," published by the Centers for Disease Control and Prevention (CDC) and "Infection Prevention and Control in Pediatric Ambulatory Settings," which was published in the September 2007 issue of Pediatrics, address cough and respiratory etiquette.

The Infection Prevention and Control guidelines include a table of what to do to minimize transmission of influenza and other respiratory tract pathogens. Among its listed sources are the CDC's 2007 isolation guidelines.

Several items on the list of respiratory hygiene recommendations might be controversial in ambulatory settings, says Lorry G. Rubin, MD, chief of pediatric infectious diseases for Schneider Children's Hospital of the North Shore-Long Island Jewish Health System in New Hyde Park, NY. Rubin is on the American Academy of Pediatric's (AAP) Committee on Infectious Diseases, which worked on the revised infection prevention policy statement.

For example, here are some of the recommendations listed in the AAP guidelines:

  • Educate patients and accompanying persons on the need for and components of respiratory hygiene/cough etiquette.1
  • When space and chair availability permit, cluster chairs for a coughing patient and accompanying persons at least 3 feet away from other patients.1
  • Consider having masks available to symptomatic patients by staff.1
  • In addition to hand hygiene before and after patient contact, health care personnel should consider wearing a mask when examining an ambulatory patient with suspected influenza.1

The implementation of respiratory hygiene and cough etiquette has been promulgated by the CDC in waiting areas, Rubin says.

"They came up with these because of SARS a couple of years back," Rubin says. "You may remember that there was transmission of SARS in waiting rooms of hospitals and doctors' offices."

This problem led to the concept of starting infection control when a patient walks into the door of an ambulatory facility or emergency department, Rubin explains.

"So these guidelines are designed to prevent transmission of SARS or to decrease influenza transmission, and they're probably relevant for many respiratory pathogens," he adds.

"This is about teaching patients through signs and education to have cloth available, to cough into their elbow instead of hands, to use hand hygiene, and to use hand hygiene after handling respiratory secretions," Rubin says. We have a hand sanitizer next to the elevator so people can give themselves a squirt when they enter the elevator."

These types of precautions would be very new for most ambulatory practices, Rubin says.

For example, people often have been taught to cough into their hands, and coughing into the elbow might seem odd.

But the idea is that many respiratory pathogens are transmitted by fingers. When people cough into their hands, they might shake someone's hand or grab a telephone or push a button to an elevator before they are able to wash or sanitize their hands, Rubin explains.

"These practices might be more practical for adults than for pediatric practices," he notes. "If a person comes into the office with certain symptoms of a cough and respiratory secretions, then you offer the person a mask while he or she is in the waiting area, and that's impractical for children of certain ages."

Also the notion that a patient will be treated by a health care practitioner with a mask is a foreign experience to many patients in outpatient pediatric settings, Rubin says.

The CDC has free posters that outpatient clinics and offices could display about respiratory hygiene and the flu, says Vicki L. Brinsko, RN, CIC, infection control coordinator at the Vanderbilt University Medical center in Nashville, TN. Brinsko is on the Healthcare Infection Control Practices Advisory Committee, which revised the isolation precautions guidelines.

"These will help especially as we approach the upcoming flu season, and in pediatric settings you have RSV starting up," Brinsko says.

Another strategy is to create "sneeze stations," she suggests. "In the Vanderbilt clinic we have sneeze stations where tissues are available, along with hand gel and a garbage can to place the tissue in after you've finished using it," Brinsko says. "Doctors' offices can offer tissues or masks to people who say, 'I've got this really bad, and I think I might have the flu.'"

The doctors' office should keep a tissue box at hand and have the staff checking in patients offer them tissues so they won't contaminate other patients, Brinsko adds.

The isolation guidelines go into details about what defines respiratory hygiene and cough etiquette, as well as how to perform hand hygiene after handling respiratory secretions, she says.

"Put an emphasis on washing hands and practice hand hygiene with alcohol gel with every patient," Brinsko suggests. "A lot of those little masks come in boxes that are pop-up, almost like a Kleenex, and they're not intrusive when they're available for people to use."


  1. Committee on Infectious Diseases. Infection prevention and control in pediatric ambulatory settings. Pediatrics 2007; 120(3):660-665.