Angiotensin converting enzyme 2 (ACE2) is a target cell receptor for internalization and proliferation of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). When ACE2-highly expressed tissues are manipulated, SARS-CoV-2 containing aerosols may be generated.

Normal breathing and speaking are capable of producing aerosols so mask ventilation, suction of airway tract and bucking during tracheal intubation and extubation are clinical procedures capable of significant aerosol production.

Whilst no data have been reported on the distribution of SARS-CoV-2 in the operating room (OR), contamination in the OR can be estimated from the intensive care unit (ICU) data. ICU data showed that SARS-CoV-2 was detected on all types of surface and in air within about 4 m from coronavirus disease 2019 (COVID-19) patients.

High concentrations of SARS-CoV-2 was detected in the personal protective equipment (PPE) removal room and medical staff office.

Submicron virus-laden aerosols could result from resuspension of particles containing SARS-CoV-2 sticking the PPE surface; removal could produce the initial velocity. Supermicron virus-laden aerosol could come from floor deposited SARS-CoV-2, which were carried across different areas by medical staff (e.g., shoe).

Knowledge of aerosol generation and distribution in the OR will aid the design of strategies to reduce transmission risk.