Guidance on nebulization during the current COVID-19 pandemic

Abstract

Awareness of the risk of airborne transmission of SARS-CoV-2 makes patients hesitant about using inhaled medications that are considered as a potential source of viral transmission and immunosuppression. However, patients with asthma or COPD should continue all prescribed inhaled medications. Apparently, inhalers, including pMDIs, DPIs, or SMIs, have a low risk of contamination although characteristics of drug formulation can precipitate cough, whereas some researchers do not rule out the probability that nebulizer treatments may increase the risk of infection transmission via droplet nuclei and aerosols. Considering that aerosol therapy generates fugitive emissions that are not inhaled by the patient and are released from the device during expiration, several international professional bodies have provided recommendations for drug delivery via inhalers and in particular, nebulizers. Unfortunately, these recommendations are often in conflict with each other and do not clarify whether it is appropriate to use nebulizers during this COVID-19 pandemic. Considering what is available in literature, there are no known infection-related hazards to an uninfected patient and also a patient with COVID-19 that preclude the use of a nebulizer at home, but it fundamental that all patients, regardless of whether or not suffering from COVID-19, always follow some practical advices.

The Impact of Coronavirus Disease 2019 on Pediatric Asthma in the United States

“…Due to aerosol treatments SARS-CoV2 may persist in the air for up to two hours and may be recirculated and remain on dependent surfaces promoting virus spread. 45 There is also concern that the particles that are generated with nebulization may stimulate cough in patients which can spread the pathogen. 46 Albuterol MDI (90 mcg/puff) 4–8 puffs every 20 minutes for 3 doses, then every 1-4 hours inhalation with valve holding chamber has shown to be as effective as nebulized therapy for mild-moderate asthma exacerbation in children.…”

Vernebelung von Notfallmedikamenten im süddeutschen Rettungsdienst

“…Inwiefern ein mögliches SARS-CoV-2-Infektionsrisiko von medizinischem Fachpersonal beeinflusst wird, ist aufgrund der momentanen Studienlage unklar [ 31 ]. Eine indizierte inhalative Therapie kann und soll bei Patient*innen mit einer SARS-CoV-2-Infektion zum Schutz des Fachpersonals mit adäquater persönlicher Schutzausrüstung durchgeführt werden [ 7 , 28 ].…”

International expert opinion on the use of nebulization for pediatric asthma therapy during the COVID-19 pandemic

“…For observing strict hand hygiene, we recommend the use of soap (wash for at least 20 seconds and dry using disposable towels) or hand sanitizer (at least 70% alcohol), before and after treating patients (44). Moreover, proper aseptic technique must be used to avoid contamination of aerosol reservoirs and nebulizer medication (46,47). We recommend the use of gloves, face masks and long-sleeved disposable gowns while setting up the nebulizer and handling medication.…”

“…As such, we recommend attaching HEPA filters to the nebulizer prior to delivering medication to the patient as effective risk mitigation for the potential transmission of SARS-CoV-2 from the patient to HCPs or carers, if COVID-19 is suspected or confirmed. Use of face masks with nebulizers should be avoided due to the risk of expulsion of aerosols from the equipment during expiration and breath-holding (46,59,60). However, in very young children needing a face mask, face masks creating a tight seal must be used.…”

“…However, in very young children needing a face mask, face masks creating a tight seal must be used. A mouthpiece should be preferably used with jet and mesh nebulizers, with filters or one-way valves attached to the large-bore tubing of a jet nebulizer to avert fugitive aerosol emissions (46,59,60). A HEPA filter can be connected to the expiratory limb of a T-piece with the mouthpiece connected to the inspiratory limb of the T-piece.…”