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Aerosolization of COVID-19 and Contamination Risks During Respiratory Treatments

Federal Practitioner. 2020 April;37(4)a:160-164
April 7, 2020|Federal Practitioner
Cassandra D. Benge, PharmD, BCPS, AACC;John Alan Barwise, MBChB
Author and Disclosure Information

Cassandra Benge is a Clinical Pharmacy Specialist, and John Barwise is a Staff Physician and Medical Director of the Surgical Intensive Care Unit, both at VA Tennessee Valley Healthcare System in Nashville. John Barwise is Associate Professor of Clinical Anesthesiology at Vanderbilt University Medical Center in Nashville.
Correspondence: Cassandra Benge (cassandra.benge2@ va.gov)

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Background: Aerosolized medications are frequently administered across the health care continuum to acutely ill patients. During viral pandemics, the World Health Organization and the Centers for Disease Control and Prevention advise the application of airborne precautions when performing aerosol-generating medical procedures, such as aerosolized medications.

 

Observations: Appropriate personal protective equipment (PPE), including fit-tested particulate respirators should be worn when administering nebulized medications to patients. These PPEs have been in short supply in the US during early phases of the COVID-19 pandemic, which is increasing the risk faced by health care workers (HCWs) who are treating patients using aerosolized medications. Despite taking appropriate precautions, HCWs are becoming infected with COVID-19. This may be related to secondary exposure related to viral longevity in fugitive emissions and viability on fomites.

Conclusions: We have expanded on non-US public health recommendations to provide guidance to frontline HCWs to enhance collaboration between clinicians, who are often siloed in their clinical practices, and ultimately to protect the federal workforce, which cannot sustain a significant loss of frontline HCWs.

Recommendations

We recommend that health care systems stop business as usual and adopt public health recommendations issued by Canadian and Hong Kong health care authorities for the management of suspected or confirmed COVID-19 disease.25-28 We have further clarified and expanded on these interventions. During viral pandemics, prescribers and health care systems should:

  1. Deprescribe nebulized therapies on medical wards and intensive care units as an infection control measure. Also avoid use in any outpatient health care setting (eg, community-based clinics, EDs, triage).
  2. Avoid initiation of nebulized unproven therapies (eg, n-acetylcysteine, hypertonic saline).1
  3. Use alternative bronchodilator formulations as appropriate (eg, oral β-2 agonist, recognizing its slower onset) before prescribing nebulized agents to patients who are uncooperative or unable to follow directions needed to use a pMDI with a spacer or have experienced a prior poor response to a pMDI with spacer (eg, OptiChamber Diamond, Philips).25,27
  4.  Limit nebulized drug utilization (eg, bronchodilators, epoprostenol) to patients who are on mechanical ventilation and will receive nebulized therapies via a closed system or to patients housed in negative pressure hospital rooms.22 Use a viral filter (eg, Salter Labs system) to decrease the spread of infection for those receiving epoprostenol via face mask.25
  5. Adjust procurement practices (eg, pharmacy, logistics) to address the transition from nebulized drugs to alternatives.
  6. Add a safety net to the drug-ordering process by restricting new orders for nebulized therapies to the prior authorization process.27 Apply the exclusion criterion of suspected or definite COVID-19.
  7. Add a safety net to environmental service practices. Nursing staff should track patients who received ≥ 1 nebulizations via open (before diagnosis) or closed systems so that staff wear suitable PPE to include a N-95 mask while cleaning the room.

Conclusions

To implement the aggressive infection control guidance promulgated here, we recommend collaboration with infection control, pharmacy service (eg, prior authorization team, clinical pharmacy team, and procurement team), respiratory therapy, pulmonary and other critical care physicians, EDs, CPR committee, and other stakeholders. When making significant transitions in clinical care during a viral pandemic, guidelines must be timely, use imperative wording, and consist of easily identifiable education and/or instructions for the affected frontline staff in order to change attitudes.29 Additionally, when transitioning from nebulized bronchodilators to pMDI, educational in-services should be provided to frontline staff to avoid misconceptions regarding pMDI treatment efficacy and patients’ ability to use their pMDI with spacer.30

Acknowledgments

This material is the result of work supported with resources and the use of facilities at the VA Tennessee Valley Healthcare System in Nashville.

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