The use of nebulized pharmacotherapies during the COVID-19 pandemic

Abstract

Coronavirus disease 2019 (COVID-19), caused by the highly contagious novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in a worldwide pandemic and currently represents a major public health issue. COVID-19 has highlighted the need for clear and accurate guidance on the use of aerosol-generating procedures, such as nebulization, for the treatment of patients with respiratory diseases with or without COVID-19. Despite the lack of evidence, there is heightened concern about the potential risk of transmission of SARS-CoV-2 in the form of aerosolized respiratory droplets during the nebulized treatment of patients with COVID-19. Consequently, the use of metered-dose inhalers (MDIs) has risen considerably as an alternative to nebulized therapy, which has led to inadequate supplies of MDIs in some parts of the United States. In this article, we review and discuss the role of nebulization in patients with SARS-CoV-2 and the treatment of noninfected patients with chronic respiratory diseases. The following two important questions are addressed: (1) should nebulized therapy be used in hospital or home settings by patients infected with SARS-CoV-2; and (2) should nebulized therapy be continued in patients already using it for chronic respiratory disease management in hospital or home settings? The reviews of this paper are available via the supplemental material section.

Aerosol transmission of SARS‐CoV‐2 by children and adults during the COVID‐19 pandemic

“…49,50 Given this uncertainty, many hospitals and clinics treat nebulizer therapy as an aerosol generating procedure to protect healthcare providers from SARS-CoV-2 infection. 51 Pulmonary function testing and spirometry are not currently classified as aerosol generating procedures by the CDC, 49 though the American Thoracic Society and the American Academy of Asthma, Allergy, and Immunology recognize that pulmonary function testing has the potential to generate aerosols. [4][5][6][52][53][54] A small study of five adults undergoing pulmonary function testing demonstrated aerosol generation with tidal breathing, the forced vital capacity maneuver, and maximum voluntary ventilation, though additional studies are needed.…”

“…Nebulized therapies are classified as a “possible aerosol generating procedure” by the CDC based on conflicting data from the SARS‐CoV epidemic 49,50 . Given this uncertainty, many hospitals and clinics treat nebulizer therapy as an aerosol generating procedure to protect healthcare providers from SARS‐CoV‐2 infection 51 . Pulmonary function testing and spirometry are not currently classified as aerosol generating procedures by the CDC, 49 though the American Thoracic Society and the American Academy of Asthma, Allergy, and Immunology recognize that pulmonary function testing has the potential to generate aerosols 4–6,52–54 .…”

Contemporary Concise Review 2020: Chronic obstructive pulmonary disease

“…Nebulization may increase dispersion of patient‐emitted aerosols and usage within healthcare settings has declined due to concern for transmission of SARS‐CoV‐2 to healthcare workers 9 . Nonetheless, the degree of risk remains uncertain 10,11 …”

International expert opinion on the use of nebulization for pediatric asthma therapy during the COVID-19 pandemic

“…Withholding nebulization therapy may also lead to respiratory failure in severe cases (34). There are concerns regarding the overabundance of caution that HCPs and health institutions might exercise in their approach to the use of nebulizers that may lead to unfavourable patient outcomes (35). Hence, there is a need to shift the focus to risk-benefit assessment when it comes to the use of nebulizers in pediatric asthma management.…”