Can nebulizer treatments be used to alleviate congestion in COVID-19 patients?

Nebulizer Treatments in COVID-19 Patients with Congestion

Nebulizer treatments can be used in COVID-19 patients with congestion, but they should be avoided when alternative delivery methods (metered-dose inhalers with spacers) are feasible, and when used, strict infection control protocols must be followed. 1

Key Principle: Nebulizers Are Not Inherently Contraindicated

The concern about nebulizers in COVID-19 stems from confusion between two distinct aerosol types 1:

• Medicinal aerosols (from the nebulizer medication) derive from a non-patient source and have not been shown to carry viral particles
• Bioaerosols (patient's exhaled breath) are the actual vector for viral transmission
• The International Society of Aerosols in Medicine clarifies that medical aerosols becoming contaminated in the lungs before exhalation is not supported by evidence 1

When Nebulizers Should Be Avoided

Switch to metered-dose inhalers (MDIs) with spacers whenever possible 1, 2:

• The Global Initiative for Asthma and Global Initiative for Chronic Obstructive Lung Disease both recommend avoiding nebulizers where COVID-19 is confirmed or suspected if inhalers can be used instead 1
• Nebulized medications should be avoided in general ward settings, with spacers used as the preferred alternative 2

When Nebulizers Are Acceptable or Necessary

Nebulizers may be required in specific clinical scenarios 1:

• Critically ill patients receiving ventilatory support - In mechanically ventilated COVID-19 patients, nebulizers may be necessary for bronchodilator delivery 1
• Patients unable to use inhalers effectively - When inhaler technique is inadequate despite instruction
• Severe respiratory distress requiring high-dose bronchodilators - When MDI delivery is insufficient

Critical Safety Requirements When Using Nebulizers

Equipment Selection

Use vibrating mesh nebulizers (VMN) in ventilated patients 1:

• VMNs allow medication addition without breaking the ventilator circuit
• Breaking the circuit generates aerosol from potentially infectious condensate 1
• If jet nebulizers must be used, employ a valved T-adapter in line with the ventilator circuit 1

Infection Control Measures

Implement strict aerosol precautions 1:

• Healthcare workers must wear appropriate PPE including FFP2/FFP3 respirators (N95 equivalent), eye protection, gowns, and gloves 1
• Administer nebulizers in negative pressure rooms or single-patient rooms when available 1
• The Surviving Sepsis Campaign recognizes nebulized treatment as an aerosol-generating procedure requiring fitted respirators 1

For Non-Ventilated Patients

Simple mask delivery may pose lower risk than previously thought 1:

• Ireland's Health Protection Surveillance Centre notes that nebulized medications via simple mask show low levels of droplet dispersion and unlikely pose increased transmission risk 1
• However, this applies when healthcare workers are not close to the airway during administration 1

Alternative Respiratory Support Strategies

Before resorting to nebulizers for congestion management, consider 1:

Oxygen Delivery Options

• High-flow nasal cannula (HFNC) or noninvasive CPAP for hypoxemic respiratory failure 1
• Target SpO2 92-96% in patients without chronic lung disease 2
• HFNC delivers 30-60 L/min of humidified heated gas and may reduce intubation needs 1

Escalation Pathway

Monitor closely for treatment failure 1:

• If no improvement or worsening within 1-2 hours on HFNC/NIV, proceed to intubation and invasive mechanical ventilation 1
• For moderate to severe ARDS (PaO2/FiO2 < 150 mmHg), use lung-protective ventilation with prone positioning >12 hours daily 1

Common Pitfalls to Avoid

1. Do not delay switching to inhalers - The default should be MDI with spacer unless there is a specific contraindication 1, 2

2. Do not use nebulizers without proper PPE - Standard surgical masks are insufficient; fitted respirators are required 1

3. Do not break ventilator circuits unnecessarily - Use in-line VMNs to maintain circuit integrity 1

4. Do not confuse medicinal aerosols with bioaerosols - The medication itself is not the infection risk; the patient's exhaled breath is 1

5. Do not use nebulizers for routine congestion - Reserve for situations where bronchodilation is specifically needed and inhalers are inadequate 1, 2

Practical Algorithm for Decision-Making

Step 1: Can the patient use an MDI with spacer effectively?

• Yes → Use MDI with spacer 1, 2
• No → Proceed to Step 2

Step 2: Is the patient mechanically ventilated?

• Yes → Use in-line vibrating mesh nebulizer without breaking circuit 1
• No → Proceed to Step 3

Step 3: Is bronchodilator therapy specifically indicated (bronchospasm, wheezing)?

• Yes → Use nebulizer with full PPE in appropriate room 1
• No → Consider alternative therapies for congestion (humidification, positioning, suctioning if intubated) 1

Step 4: Ensure proper infection control throughout treatment 1