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The current pandemic of COVID-19 cases demands greater infection control precautions. Nebulizers generate aerosol particles in the size of 1-5 µm that can carry bacteria and viruses into the deep lung. The risk of infection transmission via droplet nuclei and aerosols may increase during nebulizer treatments because of the potential to generate a high volume of respiratory aerosols that may be propelled over a longer distance than that involved in natural dispersion pattern (1). Furthermore, the larger particles may stimulate both patients' and bystanders' cough and thus increase the risk of spreading the disease (2). Nebulizer therapy in patients with pandemic COVID-19 infection has the potential to transmit potentially viable COVID-19 to susceptible bystander hosts.
In recent years there has been a welcome shift, in some centers, from the use of nebulizers to metered dose inhalers (pMDI) with Valved-Holding Chambers (VHCs). In Alberta Canada for example, any order for nebulizer is now restricted and nebulizer is only to be used in the following situations:
1. Severe, life-threatening respiratory disease (e.g., those with severe or impending respiratory arrest, those with hypoventilation or ventilation compromise, continuous nebulization, end-stage COPD, cystic fibrosis); OR
2. Patients who are uncooperative or are unable to follow the directions required for a metered-dose inhaler (MDI) with spacer use; OR
3. Patients with a history of poor response to MDI with spacer.
However, despite a large body of evidence suggesting their lack of superiority or inferiority, compared to MDI +VHC (3), the nebulizer is still widely used in many healthcare facilities (especially in the USA).
Given the current outbreak of COVID-19, Alberta Health Services (AHS) in Canada has now requested to reconsider any plan or order for a nebulizer therapy. To reduce the risk of transmission of all infectious respiratory illnesses in healthcare facilities we would encourage all caregivers in all other provinces to align with the above restrictions and seriously consider avoiding the use of nebulizers. Keeping our patients and staff safety should be our priority.
References
1. Tang JW, Li Y, Eames I, Chan PKS, Ridgway GL. Factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises. J Hosp Infect 2006;64:100-14.
2. Public Health Agency of Canada. 2011. Prevention and Control of Influenza during a Pandemic for All Healthcare Settings. Annex F. Retrieved from http://www.phac-aspc.gc.ca/cpip-pclcpi/assets/pdf/ann-f-eng.pdf.
3. Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma.
Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD000052. DOI: 10.1002/14651858.CD000052.pub2.