Infection Control Guidelines for Respiratory Therapy Services Infection Prevention in Respiratory Therapy Services Dr. NAHLA ABDEL KADERوMD, PhD. INFECTION CONTROL CONSULTANT, MOH INFECTION CONTROL CBAHI SURVEYOR Infection Control Director, KKH.

1. ١
KING KHALID HOSPITAL
INFECTION PREVENTION
AND
CONTROL MANUAL
RESPIRATORY THERAPY
Dr. Nahla Abdel Kader, MD, PhD.
Infection Control Consultant, MOH
Infection Control CBAHI Surveyor
Infection Prevention Control Director
KKH.

2. ٢
DEFINITION
To describe Infection Control standards for the respiratory
therapy services and to avoid any improper handling of
respiratory care equipment that might lead to increased
incidence of nosocomial infections
COMMENTS
1. Certain interventions used by the Respiratory therapy service may influence
infection risks to patients and HCWs.
2. Mechanical ventilation, ventilator circuit channels, handling of condensate, use of
nebulizers, suction catheters and humidification methods are potential infection risks.
3. Respiratory care devices that touch mucous membranes are classified as semicritical
and must be sterilized. When these items can not be sterilized they may have highlevel disinfection

3. ٣
PROCEDURE
A. Standard Precautions:
1. Use standard precautions for all patient care
2. Use personal protective equipment (PPE) singly or in
combination for any /all of the following procedures as
indicated.
3. Wear gloves for handling respiratory secretions and objects
contaminated with respiratory secretions of any patient.
4. Wear facial protection when contamination of the face with
aerosolized particles is likely.
5. Wear gown/ plastic apron when soiling with respiratory
secretions from a patient is likely.
6. Change the gown / plastic apron after such contact, and
before providing care to another patient.

4. ٤
Next…PROCEDURE
B. Hand hygiene:
1. Wash or cleanse hands thoroughly before
and after all contact with the patient and the
patient’s environment refer to ICM-II-04
Hand Hygiene.
2. Wash and dry or cleanse hands before and
after glove use refer to ICM-II-04 Hand
Hygiene.

5. ٥
Next…PROCEDURE
C. Mechanical Ventilation and Circuit Changes:
1. Ensure that patient is positioned with head elevated at 30○-45○
except during postural drainage procedures, to minimize
aspiration of secretions.
2. Use high-efficiency bacterial filters in the breathing circuit of
the ventilation unit.
a. Use filters on the inspiratory limb to eliminate contaminated
fluids from entering the inspired gas thereby contaminating
of the ventilator.
b. Place bacterial filters appropriately to avoid any potential
interference to the operating characteristics of the ventilator
by impeding high gas flows.
c. Carefully test reusable filters periodically to ensure efficient
functioning.
3. Use closed continuous-feed humidification on all ventilator
circuits to minimize/ prevent aerosols thus preventing
transmission of bacteria from the humidifier reservoir to
patients

6. ٦
Next…PROCEDURE
4. Heated humidification systems often operate at
temperatures that reduce/ eliminate bacterial
pathogens. Use sterile water only to fill humidifiers
and change every 24 hours. Tap or distilled water may
harbor Legionella spp. That is more heat resistant
than other bacteria.
5. Sterilize or high-level disinfect circuits, humidifiers
and nebulizers between patients.
6. Do not routinely change the ventilator circuit used
with a particular patient more frequently than 48
hours.
7. Frequent circuit-change intervals have been identified
as a risk factor for increased Ventilator associated
pneumonia.

7. ٧
Next…PROCEDURE
D. Condensate:
1. Drain and discard condensate that collects in the tubing of the
ventilator to prevent it draining towards the patient.
2. Use water traps to minimize spillage.
a. Place traps appropriately in the ventilator circuits so as to allow
gravity to drain condensate continuously away from the patient.
3. Micro-organisms contaminate condensate and must be treated as
waste and properly dispose of it through the standard hospital
waste system.
4. Use heated wire circuits to reduce/ eliminate condensate formation
in the ventilator circuit.
a. Set heated wire circuits so that a small amount of condensate forms
on the inspiratory limb of the circuit, indicating 100% relative
humidity.
b. Adjust heated wire circuit properly to deliver appropriate humidity
to the patient.
c. If humidity is decreased, it will result in damage to the epithelium of
the respiratory tract with potential occlusion of artificial airways
especially in infants and small children.

8. ٨
Next…PROCEDURE
5. Heat-Moisture Exchangers (HMEs) is another approach to
heat/humidify inspirited gas and reduces condensate formation.
NB: HMEs can increase dead space and resistance to breathing and at
the same time providing less humidity than active systems
previously discussed, resulting in thick plugging secretions in some
patients. To be effective, >70% of the gas entering the airway must
be exhaled through the HMEs; so when leaks occur (e.g., with
broncho pulmonary fistulae or cuffless endotracheal tubes), active
humidification systems can be more effective.
a. There is no CDC recommendation for preferential use of HMEs
rather than heated humidifier to prevent nosocomial pneumonia.
b. The HMEs, should be changed when gross contamination or
mechanical dysfunction of the device is present, commonly 24
hours.
c. Vent circuits should not routinely be changed when HME is in use
on a patient.
d. HMEs designed to act as bacterial filters have not been proven to
significantly reduce Ventilator- Associated Pneumonia (VAP) over
other less expensive HMEs.
e. Place HMEs between the ventilator circuit and the patient’s airway.

9. ٩
Next…PROCEDURE
E. Nebulizers:
1. Large-volume nebulizers and mist tents:
a. Sterilize or high-level disinfect large volume nebulizers, mist
tents, and hoods between patients, and after every 24 hours of
use on the same patient.
2. Room humidifiers that create aerosols have been associated
with healthcare associated pneumonia, secondary to
contamination of their reservoir. The CDC recommends that
aerosol-generating room humidifiers not be used unless they
can be sterilized or high-level disinfected every 24 hours and
filled only with sterile fluids.
3. Change disposable large volume nebulizers every 72 hrs.
4. Small volume medication nebulizers: Handheld and inline:
a. Sterilize or disinfect nebulizers between patients.
Sterilize/disinfect or rinse with sterile water and air dry after
each treatment on the same patient.
b. Use only sterile fluids and dispense aseptically.
c. Remove inline nebulizers from the ventilator circuit between
treatments, then disinfect or rinse nebulizers with sterile water
and air dry on the same patient.

10. ١٠
Next…PROCEDURE
F. Suction catheters:
1. Open Suction System: Sterile Single-use catheters
a. Use sterile single catheters and sterile technique when
suctioning with open systems.
b. Use sterile water to flush catheter while suctioning.
c. Carefully dispose of used catheter in regular hospital waste
system.
d. Use sterile gloves and a surgical mask for suctioning.
(N95/Particulate mask for PMTB)
2. Closed-suction systems:
a. Use only sterile fluid to flush secretions from the suction
catheter.
b. Change suction collection tubing and canisters between
patients.
c. Change in line suction catheters when grossly soiled or
malfunctioning.

11. ١١
Next…PROCEDURE
G. Resuscitation bags:
1. Rinse immediately with sterile water when the bag valve is
visibly soiled with secretions for use on the same patient.
2. Sterilize or high-level disinfect bags between patients.
3. Wash hands before and after all contact with patient and
patient equipment.
H. Artificial airways:
1. Place patient with head up at 30 to 40 degree angle during use
of artificial airways (unless contraindicated) especially during
feedings and for one hour after.
2. Do not routinely deflate the cuff of the endotracheal tube to
determine the filling volume of the cuff. Alternative techniques
to assure proper cuff pressure (such as minimal leak or
minimal occluding pressure) should be substituted.
3. Perform tracheostomy when indicated under sterile conditions.
Elective tracheostomy should be performed in the operating
room.
4. Use aseptic technique to replace tracheal tube.
a. Replace tube with one that has undergone sterilization or highlevel disinfection

12. ١٢
Next…PROCEDURE
I. Immobility:
1. Turn patients from the supine to lateral position every 2
hours. Encourage sit-up regimens as tolerated.
2. Patients receiving mechanical ventilation with a
nasogastric or other enteral tube in place should be
positioned with head elevated at an angle of 30 to 45
degrees.
J. Provision of oxygen by mask or cannula:
1. Change the tubing, as well as any device such as a cannula
and mask, used to administer oxygen from a wall outlet,
between patients.
2. Restrict the use of Bubble Type Humidifiers (BTHs) to
appropriate situations. Humidifiers are not indicated for
oxygen flows less than 4L/minute in adult patients under
normal conditions. When operated at flows above 10
L/minute, a standard unheated BTH designed for oxygen
delivery is less efficient as a humidifier and may create
aerosols that can transmit bacteria

13. ١٣
Next…PROCEDURE
K. Provision of diagnostic testing:
1. Percutaneous blood gases:
a. Perform hand hygiene and use clean gloves.
b. Perform adequate skin preparation on the patient using hospital
approved antiseptic.
c. Use sterile supplies.
d. Do not precool syringes by submerging in ice water.
e. Avoid repeating unsuccessful arterial punctures with the same
needle or cannula.
f. Handle all body fluids as if contaminated.
g. Dispose/transport specimens as appropriate.
2. Pulse oximetry:
a. Disinfect probes as thoroughly as possible, and do not use over
broken skin.
b. Avoid use of clip-on probes over edematous areas. Check site
frequently, reposition as necessary.
c. Reposition all probes at appropriate time intervals in accordance
with manufacturer’s recommendation

14. ١٤
Next…PROCEDURE
3. Pulmonary function testing (PFT):
h. Disinfect surfaces of device that come into patient
contact, between uses. Do not routinely disinfect the
internal machinery of PFT machines between uses.
i. Sterilize or disinfect mouthpieces and nose clips
between patients.
NB: The use of low-resistance, high-efficiency filters has
been advocated for use between the mouthpiece and
the spirometer to minimize contamination between
device and patient. This filter may also reduce HCW
exposure to droplet nuclei generated by the patient
during forced expiratory maneuvers.

15. ١٥
Next…PROCEDURE
4. Sputum induction for specimen collection:
a. Sterilize or high-level disinfect the nebulizers between
patients. Clean and disinfect all surfaces on
equipment that patient’s respiratory secretion would
contaminate during procedures.
b. Perform sputum inductions in a private room with six
air exchanges per hour if possible. Keep door closed
during procedure.
c. Wear a surgical mask or particulate respirator
during the sputum induction.
d. Ask patient’s visitors to leave the room during the
sputum induction.

16. ١٦
Next…PROCEDURE
L. Cleaning and disinfection of respiratory-care devices
a. Thoroughly clean all equipment before disinfection and/or
sterilization. Use methods of sterilization such as
pasteurization at 75○C for 30 minutes for items that cannot
be sterilized by ethylene oxide or heat.
b. Use only sterile water when a device needs to be rinsed after
it has been disinfected. Tap water or locally prepared
distilled water may harbor microorganisms that can cause
pneumonia.
c. Do not reprocess equipment and devices that are
manufactured “for single use only”; refer to ICM – IX-03
Reprocessing/ Reuse of Disposable Items.
NB: Proper cleaning and sterilization or high-level
disinfection of reusable equipment is important to reduce
infection. Respiratory-care devices have been classified as
semicritical because they come into contact with mucous
membranes but do not ordinarily penetrate body surfaces

17. ١٧