The Centers for Disease Control and Prevention (CDC) recommends taking precautions when performing aerosol-generating procedures (AGPs). The healthcare provider in the room should wear an N95 or higher-level respirator, and the number of healthcare providers present during the procedure should be limited only to those essential for patient care and procedure support. Aerosol generating procedures should ideally take place in an airborne infection isolation room (AIIR), and the procedure room should be cleaned and disinfected promptly. Nebulizer therapy use corresponds to high-risk exposure for healthcare professionals. [1]
If nebulization is being used in clinical settings for a patient with COVID-19, the American College of Allergy, Asthma, and Immunology (AAAI) recommends healthcare workers use full PPE (gown, gloves, eye protection, and a respiratory mask [e.g. N95]) when having close contact with the patient while they are getting a nebulization. There are no clear guidelines for suspected or unknown COVID-19 patients. In the absence of official recommendations, one expert suggests using patient history and professional judgment (i.e. if the patient had a recent travel history, it may be prudent to act as if there is a SARS-COV-2 infection). [2], [3]
The AAAI recommends continuing routine asthma to control symptoms. Patients diagnosed with COVID-19 or suspect to have COVID-19 and are using a nebulizer at home should be aware that the virus may persist in droplets in the air for 1-2 hours. It is recommended that albuterol be nebulized in a location that minimizes exposure to members of your household who aren’t infected. [2], [3]
The Global Initiative for Asthma (GINA) recommends against the use of nebulizers (when possible) due to the increased risk of spreading COVID-19 to other patients and healthcare personnel. [4]
A letter from Canadian respirologists warns that COVID-19 demands greater infection control and precautions concerning the use of nebulizers. They state that nebulizers generate aerosol particles in the size of 1-5 micrometers, which can carry bacteria and viruses into the deep lung. Therefore the risk of bystander infection via droplet nuclei and aerosols may increase during nebulizer treatments because of the potential to generate a high volume of respiratory aerosols. In Alberta, Canada, nebulizer use is now restricted, only to be used in the following situations: patients with severe, life-threatening disease (respiratory arrest, end-stage COPD, cystic fibrosis); patients uncooperative or unable to follow directions for a metered-dose inhaler (MDI) with spacer; or patients with a history of poor response to MDI with spacer. The authors note that, though there is a lack of evidence showing superiority or inferiority of nebulizers to MDI with valved holding-chamber, nebulizers are still widely used. They encourage all caregivers to align with these restrictions and avoid nebulizers unless absolutely necessary in order to keep patients and staff safe. [5]
An article discusses the aerosol transmission of different diseases, including coronavirus (SARS), and ways to prevent infection. Short-range transmission implies that air that flows between individuals may interact to infect one another. The use of oxygen masks and nebulizers may generate a short-range infectious aerosol (<1 m) that could potentially infect healthcare workers and other patients. Also note that some droplets generated by such masks can evaporate to become droplet nuclei, which can transmit infection over longer distances, achieving more of a long-range or airborne quality. It is possible to reduce the risk of aerosol transmission by altering ventilation parameters in healthcare environments. Reducing infection risk also requires the use of PPE, contact-transmission precautions (hand-washing, avoid touching mucous membranes), keeping isolation room doors closed, manipulation of airflow in various ways (negative pressure rooms, sliding doors) can help reduce airborne concentrations of infectious droplets, and proper quarantine and isolation procedures. [6]