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Nebulized Versus MDI Medication Administration in COVID-19 Patients

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Nebulized Versus MDI Medication Administration in COVID-19 Patients Nebulized versus MDI Medication Administration in COVID-19 patients Background Nebulizers are reported to increase droplet dispersion, causing uncertainty in use in COVID patients. A national shortage of MDI’s has led to difficulty obtaining for ideal target populations. Through review of literature and other institution guidelines, the below are AMITA Health recommendations for use of MDI’s and nebulizers. Recommendations: 1. Medicated aerosol should be absolutely limited to true indication, including short-acting bronchodilator for patients with reactive airways or chronic airway obstruction. Pneumonia or hypoxemia alone is NOT an indication. 2. Aerosol nebulization is considered to be a high risk for transmission and requires gown, gloves, N95 respirator, and eye protection and a negative airflow room is preferred (if available) Patients who are not in negative pressure room should receive priority for MDI’s 3. Preferred route of administration should follow recommendations seen in the flowchart below – either: • AeroEclipse breath-actuated nebulizer (BAN) with exhalation filter (or an equivalent filter product) as shown in the pictures below for nebulizer administration, OR • MDI with valved holding chamber (Aerochamber) (hospitals have limited MDI supply due to current national demand of products) 4. Consider using corrugated tubing and avoid all mask treatments. Ensure patient breathes in and out through the device. 5. If the patient is intubated and placed on mechanical ventilation, medicated aerosol will be delivered by Aerogen nebulizer in-line with the vent circuit. The ventilator will have a bacterial/viral (BV) filter on the exhalation port to eliminate contaminated exhalate. Assessment • Engineering controls may help prevent droplet dispersion7 o Negative pressure rooms or Expiratory or HEPA filters on ventilator • AMITA Health’s current ventilators have closed circuits which can allow delivery of the nebulized medications in intubated patients without droplet risk o HEPA filter added to exhalation limb - Changed Q24hr • MDIs with spacer may be beneficial in non-intubated COVID-19 patients in preventing transmission o Limited drug supply is a concern • Respiratory therapy administers nebulizer therapy. If staffing shortage, nurses would need to be trained to administer nebulized treatments Page 29 Nebulized versus MDI Medication Administration Decision Tree Patient requires respiratory Rx treatment COVID-19 Negative COVID-19 PUI OR OR No suspicion Confirmed COVID-19 NOT NOT Intubated Intubated Intubated Intubated Nebulizers MDI or DPIs* with Nebulizers spacer or DPI* PUI= person under investigation; DPI= dry powder inhaler; MDI= metered dose inhaler * DPIs are preferred if patient’s inspiratory capacity is sufficient to activate the inhaler Respiratory Formulary Products Available (Supply may vary at each AMITA Hospital) Drug Class Nebulizer Metered Dose Inhalers Dry Powdered Inhalers Short Acting Beta Agonist Albuterol Albuterol N/A (SABA) (Proair, Proventil, Ventolin) Anticholinergic (AC) Ipratropium Ipratropium (Atrovent) Umeclidinium (Incruse Ellipta) Ipratropium/albuterol Ipratropium/albuterol Combination SABA/ AC N/A (DuoNeb) (Combivent) Inhaled Corticosteroid Budesonide (Pulmicort) N/A Fluticasone furoate (Arnuity Ellipta) (ICS) Long Acting Beta Agonist Formoterol (Perforomist) N/A N/A (LABA)** Umeclidinium/Vilanterol AC/LABA N/A N/A (Anoro Ellipta) ICS/LABA N/A N/A Fluticasone/Vilanterol (Breo Ellipta) ** LABAs only available at the Legacy Presence hospitals at this time Page 30 Literature on Droplet Dispersion and Recommendation Statements Report Objective N Results 2003 NEJM on SARS1 Characterization 138 69 infected healthcare workers and 16 med of SARS pts in students; authors theorized that one of the Hong Kong possible reasons for transmission to these patients may have been spread of disease by droplet using nebulized inhalers 2009 Respir Care on MDI vs Survey 50 MDI with spacer was acceptable and preferred by Neb during SARS2 assessment on high percentage of patients during SARS outbreak patients’ and nurses’ perspective on MDI vs Neb in Singapore Canadian Medical Response to an -- Response letter to a growing concern article in Association Journal (CMAJ)3 article regarding Canada which stated to consider switching from growing COVID in nebulizers to MDI to minimize transmission risk Canada (primarily in non-intubated patients). CDC4 Guidance for EMS -- Recommended precautions for aerosol generating treatments such as nebulizer as it may increase transmission. (primarily in non-intubated patients) Expert consensus on Chinese expert -- Recommends MDI with spacer in non-intubated preventing nosocomial consensus for and nebulizer for intubated transmission during COVID respiratory care for critically ill patients infected by 2019 novel coronavirus pneumonia in China5 County of San Diego Health Route of inhaler -- Recommends MDI especially in EMS services and Human Services during COVID (primarily non-intubated) Agency6 outbreak References: 1. Lee N, Hui D, Wu A, et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med. 2003;348(20):1986- 94. 2. Khoo SM, Tan LK, Said N, Lim TK. Metered-dose inhaler with spacer instead of nebulizer during the outbreak of severe acute respiratory syndrome in Singapore. Respir Care. 2009;54(7):855-60. 3. https://www.cmaj.ca/content/re-transmission-corona-virus-nebulizer-serious-underappreciated-risk 4. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html 5. [Expert consensus on preventing nosocomial transmission during respiratory care for critically ill patients infected by 2019 novel coronavirus pneumonia]. Zhonghua Jie He He Hu Xi Za Zhi. 2020;17:E020. 6. https://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/EMS/Medical_Director_Report/CoSD%20EMS%20COVID% 2019%20MDI%20Option%20Approval%20Memo.pdf 7. Tsai RJ et al. Precautionary practices of respiratory therapists and other practitioners who administer aerosolized medications. Respir Care. 2015 Oct; 60(10): 1409–1417. Page 31 .
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