Data revealed that 80.5% of patients experienced improved aeration, as determined by respiratory therapist assessments of breath sounds and patient interviews post-treatment. Automated dispensing and purchasing records showed a significant reduction in the use of albuterol MDIs compared to pre-protocol levels, with sufficient stock maintained throughout the evaluation period to prevent delays or omissions in therapy. The novel protocol also eliminated the need for additional staff to manage disinfection processes. Despite the absence of a control group due to the operational constraints of the pandemic, the findings align with prior research demonstrating comparable efficacy between MDIs with spacers and nebulized treatments. This innovative protocol highlights a feasible and resource-efficient strategy for conserving essential medications during public health emergencies while ensuring patient safety and care continuity. Future studies should address cross-contamination risks and incorporate objective pulmonary function measurements to further validate these outcomes. [1]
A 2012 article evaluated the feasibility, cost-effectiveness, and infection control implications of implementing an inhaler optimization protocol in hospitals. The “common canister program” involved the use of shared aerosol inhalers coupled with patient-specific one-way valved spacers and a rigorous cleaning protocol. Data were synthesized from ten microbiological studies across diverse healthcare settings, which consistently demonstrated that the program posed no significant risk of cross-contamination when protocols were adhered to. The studies assessed contamination by culturing inhaler components before and after use, with results uniformly showing minimal or no bacterial growth. Organisms detected in rare instances, such as coagulase-negative Staphylococcus or Enterococcus, were identified as likely environmental contaminants rather than pathogens of respiratory origin. The findings underscored the program’s safety when accompanied by proper training and hospital-wide education. [2]
The inhaler optimization protocol also resulted in economic benefits, with estimated reductions in inhaler-related expenditures by up to 50%; savings associated with protocol implementation are presented in Table 1. Potential cost savings were attributed to decreased inhaler waste, streamlined inventory management, and reduced dispensing errors. Workflow efficiency was also enhanced with the protocol by eliminating treatment delays associated with inhaler transport and restocking. Additional advantages included lower environmental waste, improved medication adherence post-discharge, and comparable, if not superior, therapeutic outcomes when using spacers as opposed to nebulizers. Despite its demonstrated safety and cost-efficiency, challenges to widespread adoption were noted, particularly concerns about infection control perceptions and possible resistance to altering entrenched clinical practices. [2]
A 2016 randomized controlled trial (RCT) evaluated the safety and clinical outcomes associated with shared canister inhalation therapy in mechanically ventilated adult patients (N= 353) over 12 months. Patients were excluded if they were undergoing a lung transplant, experiencing status asthmaticus, neutropenia, infected with antibiotic-resistant bacteria (e.g. MRSA, VRE, C. diff), or respiratory viruses (e.g. influenza A, B, rhinovirus, or adenovirus). Patients were assigned to either receive shared canister therapy (n= 201) or single canister therapy (n= 152). Respiratory therapists followed a pre- and post-administration canister cleaning protocol using 70% isopropyl alcohol prep pads, hand hygiene, and personal protective equipment (PPE). While ventilator-associated events occurred more often in the shared canister group versus the single-canister group, there were no significant differences between the two groups after adjusting for relevant confounders (4.5% vs. 0.7%; odds ratio [OR] 6.931; 95% CI 2.910 to 20.166; p= 0.07]), and no significant differences between the type of ventilator associated event such as VAP (7.0% VS 4.6%; OR 1.484; 95% CI 0.916 to 2.408; p= 0.41]). Additionally, no differences were found in the duration of mechanical ventilation, use of vasopressors and antibiotics, and patient mortality. Notably, the group receiving shared canister MDI therapy had a cost savings of $43,657.99 due to the use of 299 fewer MDIs. However, the authors conclude that the minimal yet prevalent risk of ventilator-associated events with shared canister inhalation therapy can potentially negate the cost savings from their use and further studies are needed to determine the overall safety of the method. [3]
A 2014 study establishing a quality control program for shared MDIs was conducted from December 2012 to May 2013 at a 257-bed acute care facility. Bacterial cultures were obtained from the MDI mouthpiece and canister spray tip before pharmacy cleaning (n= 17), after cleaning (n= 33), and from new/unused controls (n= 33) each month. The hospital’s protocol, approved by the Pharmacy and Therapeutics Committee in 2000, involves connecting the holding chamber to the MDI while wearing gloves. The patient places their mouth on the chamber mouthpiece, while the provider actuates the MDI into the chamber and instructs the patient to inhale, ensuring no direct contact with the MDI itself. The mouthpiece is wiped with an alcohol swab before and after use. MDIs and chambers are stored in patient-specific bins between uses and returned to the pharmacy upon discharge or therapy discontinuation. Patients in burn units, on ventilators, or in isolation rooms were excluded from shared MDI use. MDIs used in these settings are labeled for single-patient use and discarded after therapy completion. If a sticker is removed accidentally, technicians receive reports of isolation patients prior to each MDI cleaning session to verify. As per guidelines and previous studies, MDIs were cleaned three times weekly using compressed air, followed by 70% isopropyl alcohol (wipes and spray), and then air-dried. At the end of the study, no bacterial growth was detected in any group, before or after cleaning, or in the new control group. The program resulted in an 80% reduction in MDI purchases, saving approximately $130,000 during the study period. Overall, these findings suggest that MDI recycling, when paired with a strict and validated quality control program, carries a low risk of bacterial contamination. However, limitations include the small sample size and use of a swab culture method with low sensitivity (0.01 mL), which may not detect viral, fungal, or slow-growing bacterial pathogens, and can underestimate contamination risk from other respiratory or environmental organisms. [4]
An editorial published in the August 2013 examined the practice of sharing MDIs among multiple patients to determine if cross-contamination could be effectively prevented. The protocol involves wiping the MDI nozzle with an alcohol pad before and after each use and inserting it into a dedicated spacer with a one-way valve for medication administration. Proponents advocate for the practice due to increased efficiency, reduced treatment delays, and cost savings of up to 55%, while critics highlight concerns regarding the reliability of disinfection protocols and the potential for microbial transmission. Microbiological assessments conducted in various hospitals showed mixed results, with one facility reporting no detectable bacterial growth following alcohol disinfection, whereas others documented contamination, including Staphylococcus epidermidis and Streptococcus group D in approximately 5% of samples. A 2000 investigation evaluating the use of a common MDI canister protocol with the Monaghan AeroChamber found no evidence of cross-contamination, and a 2004 study of 50 patients using a similar approach reported no microbial growth upon culture analysis. However, a broader discussion in the editorial emphasized that failures in infection control practices, such as inadequate hand hygiene and inconsistent disinfection compliance, could contribute to contamination. Historical data from the Centers for Disease Control and Prevention (CDC) further underscored the risks associated with shared medical equipment, citing cases of hepatitis B and C transmission due to poor infection control. The editorial concluded that while a common MDI canister protocol may be effective under strict adherence, lapses in disinfection practices could negate cost-saving benefits by increasing the risk of nosocomial infections, particularly for immunocompromised patients. [5], [6], [7]
Finally, a 2015 commentary article analyzed the implementation of inpatient common canister (CC) protocols that involved shared MDIs among patients using individual one-way spacers and cleaning protocols. The authors noted cost savings from CC programs, including reductions in drug waste and inhaler use (43 to 80%), with studies reporting up to $303,000 saved annually. The authors did also note the concerns for infection risk, even though cross-contamination was unlikely if disinfection protocols were strictly followed, and data supporting this came from non-peer-reviewed sources. Cross-contamination rates up to five percent have been reported, and the potential for bacterial and viral transmission was unconfirmed based on methodological limitations within existing studies. The Joint Commission and the Tennessee Board of Respiratory Care caution against CC use due to safety concerns, and economic models even suggest that low infection rates could offset CC related savings. The authors suggest that nebulizers can be used as an alternative and could offer similar cost benefits with lower infection risk, and conclude that hospitals should weigh financial benefits against patient safety and adhere to these protocols before implementing them. [8]