How to nebulise in COVID era?

1. Nebulisation therapy in COVID 19 pandemic
Dr. Aditya Jindal
Interventional Pulmonologist & Intensivist
Jindal Clinics
SCO 21, Sec 20D, Chandigarh
DM Pulmonary and Critical Care Medicine (PGI Chandigarh),
FCCP

2. The adult lung
with dimensions
and generations
of the airways
with predicted
aerosol
deposition
Roy pleasants et al. Respiratory care. 2018;63(6):708-733

3. Inhaler devices

4. • Widespread hand-held inhalers’ devices are
represented by
• Dry powder inhalers (DPIs)
• Pressurized metered dose inhalers (pMDIs)
• Soft mist inhalers (SMIs)
• Nebulizers are often left for the treatment of acute
conditions such as COPD exacerbations or in
patients with extremely limited self-sufficiency.
Inhaler devices??
Dolovich MB, Ahrens RC, Hess DR, et al. Chest. 2005;127(1):335–371.

5. Factors influencing optimal delivery of inhaled
drug in subjects with obstructive lung diseases
The device Drug formulation
Cognition, disease
severity, and
clinical status of
patient
Roy pleasants et al. Respiratory care. 2018;63(6):708-733

6. Advantages and disadvantages of different types of inhaler devices in
asthma and COPD
Inhaler Formulation Metering system Pros Cons
pMDI
Drug suspended or dissolved in
propellant (With surfactant or
cosolvent)
Metering valve and
reservoir
Compact and portable.
Can be used independently.
Dose counters
Slow inhalation can be achieved
Not breath actuated
Not good for elderly
Cold Freon effect
Coordination issues
Adding spacer makes it cumbersome and
costly
MDI with spacer
Drug suspended or dissolved in
propellant (With surfactant or
cosolvent)
Metering valve and
reservoir
Easy to coordinate
Decreases oropharyngeal deposition
Eliminates Cold Freon effect
DPI
Drug blend in lactose or drug
alone/drug excipient
particles/multidose blister
reservoirs
Capsules/blisters/
Compact and portable
Do not require coordination
Doesn’t contain propellants
Requires minimum inspiratory flow
Cant be used in emergencies
Difficult in patients with cognitive
impairment and elderly
Most are moisture sensitive
SMI
Aqueous solution or
suspension
Unit dose blisters or
reservoirs
Compact and portable
Doesn’t contain propellants
Smaller dose of bronchodilator is
required
Metered volume of 15 mcl limits the dose
deliver capacity
Paola Rogliani et al. Respiratory Medicine 124 (2017) 6e14

7. Device errors in asthma and COPD:
Meta analysis
• Studies in adult males and females with asthma or COPD,
reporting at least one overall or critical error, using metered
dose inhalers and dry powder inhalers were included.
• Random-effect metaanalyses were performed to estimate
device error rates and to compare pairs of devices.
H.Chrstyn et al.npj Primary Care Respiratory Medicine (2017) 27:22

8. Meta-analysis of the overall error rate frequency for pMDI in prospective/cross-sectional studies
Summary results for the MDI devices estimated an overall
error frequency of 86.8% [95% CI 79.4–91.9] of patients with
at least one error
H.Chrstyn et al.npj Primary Care Respiratory Medicine (2017) 27:22

9. Meta-analysis of the overall error rate frequency (a) for DPIs in prospective/cross-sectional
studies
H.Chrstyn et al.npj Primary Care Respiratory Medicine (2017) 27:22

10. Device errors
in asthma and
COPD:
Metaanalysis
H.Chrstyn et al.npj Primary Care Respiratory
Medicine (2017) 27:22

11. Overall and critical error rates were reported to be high
across all devices, ranging from 50–100% and 14–92%,
respectively.
Insufficient evidence to
determine differences in error rates
between different inhaler devices and their
impact on clinical outcomes. Development
of standardised checklists for each device is
need of hour!
H.Chrstyn et al.npj Primary Care Respiratory Medicine (2017) 27:22

12. Cochrane Review: Nebulizers vs pMDI vs DPI
• There is a lack of evidence in favour of one mode of delivery over
another for bronchodilators during exacerbations of COPD.
• No difference between nebulisers versus pMDI plus spacer regarding
the primary outcomes of FEV1 at one hour and safety.
• Secondary outcome: Change in FEV1 closest to one hour after dosing'
during an exacerbation of COPD, a greater improvement in FEV1
when treating with nebulisers than with pMDI plus spacers.
Bronchodilators delivered by nebuliser versus pMDI with spacer or DPI for exacerbations of COPD. Cochrane Database of Systematic Reviews 2016, Issue 8. Art.
No.: CD011826.

13. • Older, more debilitated and to have a severe disease.
• Poor coordination between the device activation and drug inhalation or by a
short inhalation time.
• Lack of a sufficient inspiratory peak flow
• Mistakes regard dose preparation and exhalation through the device prior to
inhalation
• More appropriate to match the device with the needs and the skills of the patient
How do you choose inhaler device?
No consensus on how to match patient requirements with criteria
for selecting an alternative inhaler device.
Pierachille Santus, Dejan Radovanovic, Andrea Cristiano et al.2017:11 3257–3271

14. • Drug delivery via nebulization:
• An effective alternative
• An optimal dose can be delivered during tidal
breathing.
• Can be used with diferent disease severity or
associated comorbidities,
• Overcomes the need for coordination, specific
handling and inspiratory maneuvers
Nebulized devices??
Pierachille Santus, Dejan Radovanovic, Andrea Cristiano et al.2017:11 3257–3271

15. Types of
Nebulizers
Alok G.Ghosal et al. Journal of The Association of Physicians of India.2017;65:60-73

16. L. Vecellio. Breathe Mar 2006

17. L. Vecellio. Breathe Mar 2006

18. L. Vecellio. Breathe Mar 2006

19. Patient profile for Nebulization
• Patients with severe disease and exacerbations
• During exacerbations where higher doses are needed
• Elderly patients>60 years
• Patients with physical and cognitive limitations
• Patient preference
Eur Respir J 2001; 18: 228–242
Ann Transl Med 2019;7(18):487

20. What guidelines say about
nebulization?

21. GOLD 2020
GOLD guidelines 2020

22. Algorithm to identify
OAD patients for
maintenance
nebulization
*Clinical improvement should be assessed as
recommended by the respective treatment
guidelines.
#Device technique should be assessed as per the
patient information literature provided with the
device.
+Unsatisfactory device technique is any deviation
from the recommended device technique described
in the patient information literature provided with
the device
Alok G.Ghosal et al. Journal of The Association of
Physicians of India.2017;65:60-73
Indian consensus
statement on
maintenance
nebulization

23. Guidelines
in snapshot
Cassandra D. Benge and John Alan Barwise. Federal practitioner (2020),160-163

24. Nebulized
pharmacotherapy

25. Nebulized pharmacological therapy
• Many drugs available as DPI/pMDI are now available in
nebulization form
• The long-acting agents are indicated for maintenance
treatment of COPD-associated airflow obstruction, while short-
acting bronchodilators are indicated for acute relief of
bronchospastic symptoms of COPD.

26. Drugs available
in India for
maintenance
Nebulization
Ghoshal AG, Salvi S, Dhar R, et al. J Assoc Physicians India. 2017;65(5):60-73.

27. Nebulization in COVID 19 pandemic

28. COVID 19 situation in India
• Active (24.45%) 676514 ( 3348)
• Discharged (73.64%) 2037870 ( 60091)
• Deaths (1.91%) 52889 ( 1092)
COVID-19 INDIA as on : 19 August 2020, 08:00 IST.. https://www.mohfw.gov.in/ accessed on 19.08.2020

29. INDIA
COVID 19
..Month
wise growth
https://www.who.int/docs/default-source/wrindia/situation-report/india-situation-report-27.pdf?sfvrsn=8d0d1850_2 accessed on 19.8.2020

30. Fugitive emissions during nebulization
Fugitive emission is defined
as aerosols that have been
released from the aerosol
device during patient
expiration.
It is also medical aerosols
that are not inhaled by the
patient but passes into the
atmosphere.
Previous studies: the
particle size ranges from
0.860 to 1.437 μm
Up to 50% of the generated
aerosol during therapy was
fugitive aerosol remain
airborne in the indoor
environment for several
hours .
Factors affecting fugitive emissions: The device,
interface, patient type, and flow rate of nebulizer,
dimensions and layout of the room, air turbulence,
airflow rates, and temperature impact dispersion and
decay
Ari A. Respir Med. 2020;167:105987.

31. COVID 19 transmission
• Spread by droplets generated as bioaerosols.
• Aerosol transmission of SARS-CoV-2 is plausible because the
virus can remain viable and infectious in aerosols for hours
Ari A. Respir Med. 2020;167:105987.

32. Precautions while performing nebulization in
hospitals
• Facemasks protect the wearer from splashes and sprays.
• N-95 Respirators, which filter inspired air, offer respiratory protection
• Eye protection, gown, and gloves continue to be recommended.
• Patients with known or suspected COVID-19 should be cared for in a
single-person room with the door closed. Airborne Infection Isolation
Rooms (AIIRs)
https://www.aaaai.org/ask-the-expert/nebulizers accessed on 17.8.2020
https://www.cdc.gov/coronavirus/2019-
ncov/hcp/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-
ncov%2Fhcp%2Finfection-control-faq.html#Infection-Control accessed on 17.8.2020

33. Airborne Infection Isolation Rooms (AIIRs)
Single-patient rooms at negative pressure relative to the surrounding areas,
and with a minimum of 6 air changes per hour (12 air changes per hour are
recommended for new construction or renovation).
Exhausted directly to the outside or be filtered through a high-efficiency
particulate air (HEPA) filter directly before recirculation.
Room doors should be kept closed except when entering or leaving the
room, and entry and exit should be minimized.
Facilities should monitor and document the proper negative-pressure
function of these rooms
https://www.aaaai.org/ask-the-expert/nebulizers accessed on 17.8.2020
https://www.cdc.gov/coronavirus/2019-
ncov/hcp/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-
ncov%2Fhcp%2Finfection-control-faq.html#Infection-Control accessed on 17.8.2020

34. Precautions while performing nebulization in
hospitals
• Dedicated medical equipment should be used when caring for
patients with suspected or confirmed SARS-CoV-2 infection.
• All non-dedicated, non-disposable medical equipment used for patient care should be
cleaned and disinfected according to manufacturer’s instructions and facility policies.
• Ensure that environmental cleaning and disinfection procedures are
followed consistently and correctly.
https://www.aaaai.org/ask-the-expert/nebulizers accessed on 17.8.2020
https://www.cdc.gov/coronavirus/2019-
ncov/hcp/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019
-ncov%2Fhcp%2Finfection-control-faq.html#Infection-Control accessed on 17.8.2020

35. Environmental control
• Routine cleaning and disinfection procedures
• 1% sodium hypochlorite is appropriate for SARS-CoV-2 in healthcare
settings, including those patient-care areas in which aerosol
generating procedures are performed.
• For nebulizers disinfection
• 70% isopropyl alcohol – 5 minutes or 3% hydrogen peroxide – 30 minutes
https://www.aaaai.org/ask-the-expert/nebulizers accessed on 17.8.2020
https://www.cdc.gov/coronavirus/2019-
ncov/hcp/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2
019-ncov%2Fhcp%2Finfection-control-faq.html#Infection-Control accessed on 17.8.2020

36. Home nebulization during COVID 19 pandemic

37. Precaution at home nebulization
• Make sure you are sitting up to take the neb.
• You should see a mist come out of the neb facemask, or mouthpiece, when you
turn on the machine.
• When the facemask is in place, make sure there is no mist leaking out the sides.
• If using a mouthpiece, place it in your mouth between your teeth. Close your
lips around the mouthpiece, so no air leaks out.
• Take slow deep breaths.
https://www.atsjournals.org/doi/pdf/10.1164/rccm.2020C9 accessed on 17.8.2020

38. Disinfection of Nebulizer at home
Before cleaning your
equipment, wash your
hands.
Then, rinse the
nebulizer cup and
facemask, or
mouthpiece, with
water and dry with a
paper towel.
At least once a day do
a deeper cleaning
using warm water and
a mild, clear
detergent.
Fill a bowl or sink with
warm water and add a
mild, clear detergent
(like dishwashing
soap). Submerge
Nebulizer Breathing
Treatments at Home
Nebulizer (neb)
breathing treatments
use an air compressor
(machine) and a cup
(nebulizer) that holds
liquid medicine.
It may also be
recommended that
you soak the nebulizer
equipment in a soapy
solution for 30
minutes, then soak in
a vinegar solution (2
parts sterile water, 1
part white vinegar) for
30 minutes.
https://www.atsjournals.org/doi/pdf/10.1164/rccm.2020C9 accessed on 17.8.2020

39. Disinfection of Nebulizer at home
• Disinfecting solutions and soaking times
• 70% isopropyl alcohol – 5 minutes
• 3% hydrogen peroxide – 30 minutes
• Disposable neb cup and tubing sets can be used for two weeks.
Reusable neb cup and tubing sets can be used for up to six month
• The air compressor machine has a filter that will need to be changed
https://www.atsjournals.org/doi/pdf/10.1164/rccm.2020C9 accessed on 17.8.2020

40. Practical
strategies for
aerosol drug
delivery to
mild-patients
with COVID-19
Ari A. Respir Med. 2020;167:105987.

41. Practical strategies
for aerosol drug
delivery to
intensive-care
patients with
COVID-19.
Ari A. Respir Med. 2020;167:105987.

42. Summary
• Inhalation therapy is the preferred route of drug administration for treating COPD.
• In comparison with pMDIs and DPIs, effective drug delivery with conventional pneumatic nebulizers
requires less intensive patient training.
• If nebulized medications need to be used in patients with COVID-19, clinicians should isolate patients in an
airborne infection isolation room (AIIR)
• Hand hygiene and double gloving should be a standard practice
• Use respirators such as N95 or FFP2 standard or equivalent, goggles/face shield, gloves, gowns, and
aprons) during aerosol therapy .
• Minimize the number of times that healthcare workers enter the rooms of COVID-19 patients by bundling
the activities/treatments and restricting others.