What is the preferred nebulizer treatment for shortness of breath (SOB) due to Coronavirus disease 2019 (COVID-19)?

Preferred Nebulizer Treatment for Shortness of Breath Due to COVID-19

For patients with shortness of breath due to COVID-19, metered-dose inhalers (MDIs) should be used instead of nebulizers whenever possible to reduce viral transmission risk, but when nebulization is necessary, a vibrating mesh nebulizer (VMN) is preferred, especially in ventilated patients, to minimize aerosol dispersion. 1

First-Line Approach

Avoid Nebulization When Possible

• Nebulization is generally discouraged in COVID-19 patients due to the risk of viral aerosolization 1
• Use MDIs with spacers as the first-line delivery method for bronchodilators when possible 1

When Nebulization is Necessary

1. Preferred Device Selection:

   • Vibrating mesh nebulizers (VMNs) are preferred over jet nebulizers 1, 2
   • VMNs produce less fugitive aerosol and can be used in closed ventilator circuits without breaking the circuit 1

2. Medication Selection:

   • Bronchodilators (albuterol/salbutamol) remain the primary treatment for bronchospasm 2, 3
   • Avoid nebulized corticosteroids in mild COVID-19 cases 4
   • For severe cases requiring oxygen support, consider:
     • Nebulized budesonide (1mg twice daily) for patients not requiring mechanical ventilation 2
     • Dornase alfa with albuterol may be beneficial for intubated patients with thick secretions 3

Safety Precautions During Nebulization

For Non-Intubated Patients:

• Place a surgical mask over the patient's face during nebulization 1
• Use a transnasal approach for bronchoscopy if needed 1
• Avoid high-flow nasal oxygen therapy during nebulization 1
• Consider using a transparent protective box to contain droplet particles 1
• Ensure proper room ventilation and healthcare worker PPE 1

For Intubated Patients:

• Use a closed circuit with viral filters in both arms 1
• Maintain cuff pressure between 25-30 cmH2O on endotracheal tubes 1
• Clamp the ventilation circuit just before introduction and withdrawal of any device 1
• Use VMNs that don't require breaking the ventilator circuit 1

Special Considerations

Severe COVID-19 Cases:

• For patients requiring oxygen or ventilatory support, systemic corticosteroids are recommended rather than nebulized ones 4
• Consider methylprednisolone (1 mg/kg IV) for severe cases, which has shown improved outcomes including reduced mortality compared to other corticosteroid regimens 2

Patients with Underlying Respiratory Conditions:

• For COPD patients with COVID-19, optimize dual bronchodilators early 5
• Use caution with inhaled corticosteroids in patients with recent pneumonia 5
• Monitor for interstitial lung disease that may worsen post-COVID infection 5

Common Pitfalls to Avoid

1. Transmission Risk:

   • Avoid breaking ventilator circuits unnecessarily 1
   • Don't use nebulizers in shared spaces without proper precautions 1

2. Medication Errors:

   • Avoid premature use of corticosteroids in mild disease 4
   • Don't withhold bronchodilators when clinically indicated due to fear of aerosolization 1

3. Ventilation Management:

   • Avoid high airway pressures during nebulization 1
   • Don't use high-flow nasal oxygen during nebulization procedures 1

By following these guidelines, clinicians can effectively manage shortness of breath in COVID-19 patients while minimizing transmission risks to healthcare workers and other patients.