Can aerosol treatment be used in patients with respiratory COVID-19 (Coronavirus Disease 2019) infection?

Aerosol Treatment in Patients with Respiratory COVID-19 Infection

Aerosol treatments can be used in patients with respiratory COVID-19 infection, but specific precautions must be implemented to minimize the risk of viral transmission to healthcare workers and others.

Risk Assessment and Considerations

Nebulized treatments have been classified as aerosol-generating procedures (AGPs) during the COVID-19 pandemic, which raises concerns about potential viral transmission 1. However, there is conflicting evidence regarding the actual risk level:

• The International Society of Aerosols in Medicine notes that medical aerosols from nebulization derive from the fluid in the nebulizer chamber (not the patient) and have not been shown to carry patient-derived viral particles 1
• The World Health Organization states that evidence is insufficient to classify nebulizer therapy as an AGP associated with COVID-19 transmission 1
• However, multiple professional organizations recommend caution and specific mitigation strategies when using nebulizers in COVID-19 patients 1

Recommendations for Healthcare Settings

When aerosol treatment is necessary for patients with COVID-19:

1. Use appropriate personal protective equipment (PPE):

   • Use fitted respirator masks (N95, FFP2, or equivalent) rather than surgical masks 1
   • Include additional PPE: gloves, gown, and eye protection (face shield or safety goggles) 1

2. Administer in an appropriate environment:

   • Perform nebulization in a negative pressure room whenever possible 1
   • If negative pressure rooms are unavailable, use a normal pressure room equipped with HEPA filters and strict door policy 1

3. Select optimal nebulizer devices:

   • For ventilated patients, vibrating mesh nebulizers (VMNs) are preferred as they maintain circuit integrity and minimize fugitive emissions 1, 2
   • For non-ventilated patients, consider using pressurized metered-dose inhalers (pMDIs) with spacers instead of nebulizers when clinically appropriate 1

4. Minimize personnel exposure:

   • Limit the number of healthcare workers present during nebulization 1
   • Ensure the procedure is performed by experienced staff to minimize duration of exposure 1

Recommendations for Home Settings

For patients requiring nebulized treatments at home:

1. Location considerations:

   • Administer treatments in locations where air is not recirculated into the house 1
   • Use areas with increased air circulation, near open windows 1
   • Consider using air purifiers in the treatment area 1

2. Device selection:

   • Jet nebulizers (JNs) with filtered mouthpieces can significantly reduce fugitive emissions 1
   • Follow manufacturer instructions for cleaning and disinfection

3. Minimize exposure to household members:

   • Reduce the number of people present during treatments 1
   • Maintain distance from others when possible

Clinical Decision-Making Algorithm

1. Assess necessity of nebulized therapy:

   • Is the medication available in a non-nebulized form (MDI, DPI)?
   • If yes and clinically appropriate, use alternative delivery method
   • If no, proceed with nebulized therapy with precautions

2. Determine treatment setting:

   • For hospitalized patients: Use negative pressure room if available
   • For outpatients: Provide clear instructions for home administration

3. Select appropriate device:

   • For ventilated patients: Use VMN with closed circuit
   • For non-ventilated patients: Consider filtered nebulizer systems

4. Implement infection control measures:

   • Ensure appropriate PPE for healthcare workers
   • Minimize personnel in treatment area
   • Follow institutional infection control protocols

Common Pitfalls and Caveats

• Do not automatically withhold nebulized treatments if clinically indicated - implement appropriate precautions instead
• Do not break ventilator circuits to add medication or change nebulizers, as this generates potentially infectious aerosols 1
• Avoid high-flow nasal oxygen around the time of nebulization due to increased aerosol generation and high oxygen consumption 1
• Be aware that different nebulizer types produce varying levels of fugitive emissions - VMNs produce significantly less than jet nebulizers 2

In conclusion, while aerosol treatments can be administered to COVID-19 patients, healthcare providers must carefully weigh the benefits against potential transmission risks and implement appropriate precautions to protect themselves and others.