Needle‐free jet injection‐induced small‐droplet aerosol formation during intralesional bleomycin therapy

Abstract

Objectives: Needle-free jet injectors are frequently used in dermatological practice. Injection-generated small-droplet aerosols could be harmful upon inhalation when chemotherapeutics, like bleomycin, are used. Here, we aim to explore jet injector-induced small-droplet aerosol formation of bleomycin in relation to air ventilation and to provide safety measures for clinical practice. Materials and Methods: With a professional particle sensor, we measured airborne aerosol particles (0.2-10.0 µm) after electronic pneumatic injection (EPI), springloaded jet injection (SLI), and needle injection (NI) of bleomycin and saline (100 μl) on ex vivo human skin. Three levels of air ventilation were explored: no ventilation, room ventilation, and room ventilation with an additional smoke evacuator. Results: EPI and SLI induced significant small-droplet aerosol formation compared with none after NI (0.2-1.0 µm; no ventilation). The largest bleomycin aerosol generation was observed for the smallest particles (0.2-1.0 µm) with 673.170 (528.802-789.453) aerosol particles/liter air (EPI; no ventilation). Room ventilation and smoke evacuation led to a reduction of ≥99% and 100% of measured aerosols, respectively. Conclusion: Jet injectors generate a high number of small-droplet aerosols, potentially introducing harmful effects to patients and healthcare personnel. Room ventilation and smoke evacuation are effective safety measures when chemotherapeutics are used in clinical practice.

Needle‐free electronically‐controlled jet injector treatment with bleomycin and lidocaine is effective and well‐tolerated in patients with recalcitrant keloids

“…This reduction was substantially smaller compared to EPI‐assisted TCA in Bik et al (POSAS reduction of resp. 27% and 34%) and spring loaded jet injector‐assisted bleomycin in Saray et al (complete flattening in 73.3%) 16,27 . These discrepancies could be related to the characteristics of the keloids in our patient population.…”

“…Therefore, adequate protective safety measures are required, including the use of goggles, gloves, and mechanical room ventilation with FFP-2/FFP-3/N95 masks or smoke evacuators which can adequately capture these aerosols. 30 Moreover, bleomycin should not be administered to pregnant or lactating women, and should also not be administered by healthcare workers that are pregnant or lactating. For this reason, it is important to inform patients and healthcare personal about the potential health hazards of chemotherapeutics such as bleomycin.…”

“…Previously, Bik et al 16 and Erlendson et al 25 investigated the effectiveness, tolerability, and patient satisfaction of intralesional EPI‐assisted TCA and 5‐Fluorouracil, respectively. Notably, in the study by Bik et al, patients who received intralesional TCA with an EPI for their keloids reported an average pain score of 4.3 during the first treatment, which exceeds the median pain score of 2.0 (IQR 1.5−2.5) observed in our study.…”

“…Moreover, jet‐injector assisted administration of chemotherapeutics such as bleomycin can cause the formation of potentially harmful aerosols. Therefore, adequate protective safety measures are required, including the use of goggles, gloves, and mechanical room ventilation with FFP‐2/FFP‐3/N95 masks or smoke evacuators which can adequately capture these aerosols 30 . Moreover, bleomycin should not be administered to pregnant or lactating women, and should also not be administered by healthcare workers that are pregnant or lactating.…”

“…In contrast to needle‐free spring‐driven jet injectors, EPI allow the adjustment of settings such as volume and pressure 15 . A recent study demonstrated the high effectiveness, good tolerability, and patient satisfaction of intralesional EPI‐assisted triamcinolone acetonide (TCA) treatment in keloids 16 …”