nebulizers

[bingbongbink]

so during covid times, for some time our hospital had converted from using nebulizers regularly to using MDIs and/or nebs on pts ok closed circuit devices such as NIPPV (bipap) or ventilators for covid positive patients and non-covid patients just bc of this risk of aerosolization

Although omicron is certainly surging and a risk, ive had a few pts come in for copd exacerbations, COVID negative, and some of our RTs are still very much afraid of dispensing nebulizers out of fear of aerosolizing - the pt is covid negative, they need nebs steroids abx etc, it is a patient safety issue

How can i expect a pt in resp distress to take an MDI (meter dose inhaler) which even stable outpatients can hardly follow simple technique?

Now take a COPD, exacerbating, dynamic hyperinflation, elevated FRC, low inspiratory capacity, increased work of breathing and you’re telling me to give them MDIs??? Give me a break- I thought the whole pt of the nebs were to inundate the resp tract, dead space and regardless of inhalation/expiratory phases of breathing bypassing all the dead space and hitting spaces that have adequate V/Q so the bronchodilating effect can take place

What are your thoughts?
What is your hospitals practice?
Do I just work at a crappy place?
Does my reasoning make sense?
Does it putt staff at risk? Nursing and RT, Docs etc

This is for nebulizers on covid negatives


Thanks

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[NewYorkDoctors]

I run a PFT lab and I keep particulate meters (PPm2.5) to monitor the room . It is a negative pressure room with hepa filtration . Under normal circumstances , the meter reads 0-5ppm . When a standard nebulizer is used it rises to levels above 300 . When a breath actuated nebulizer is used (more expensive - this one only dispenses the nebulized medication when the patient inhales by design ) , the levels rise to about 60. Hence if this were used in an open ER you betcha transmission of covid droplets can be transmitted . Now if someone were in an isolation room , then this may be less of an issue .

In general busting open a new MDI is expensive as the whole canister belongs to one patient now .

No easy answers . At my hospital , nebulization is done in single icu rooms or a negative pressure floor isolation room only if frequented by pulmonary or icu . It is not done in the open emergency room area .

 

[bingbongbink]

I run a PFT lab and I keep particulate meters (PPm2.5) to monitor the room . It is a negative pressure room with hepa filtration . Under normal circumstances , the meter reads 0-5ppm . When a standard nebulizer is used it rises to levels above 300 . When a breath actuated nebulizer is used (more expensive - this one only dispenses the nebulized medication when the patient inhales by design ) , the levels rise to about 60. Hence if this were used in an open ER you betcha transmission of covid droplets can be transmitted . Now if someone were in an isolation room , then this may be less of an issue .

In general busting open a new MDI is expensive as the whole canister belongs to one patient now .

No easy answers . At my hospital , nebulization is done in single icu rooms or a negative pressure floor isolation room only if frequented by pulmonary or icu . It is not done in the open emergency room area .

Hey thanks for the response. Very helpful to understand.

For the particulate meter (ppm 2.5) what diameter size droplet are you capturing?

We only have curtained rooms in our icu and er, so it’s very open with a walled off area with negative pressure/isolation rooms for the covid pts. On the floors they have some scattered iso room.

So in that open area, based on what your saying nebulization is a risk: however not necessarily by the particulate generated by the covid negative patient but by the general process of aerolozation, causing droplet production/particulate formation which can catch stray covid and make it transmissible?
Is that what you are saying?

 

[Radetzky]

It is an irrational fear if the patient is definitely covid negative

That said, spacers with the MDI work well and might even be better at depositing drug than a nebuliser

 

[Bobblehead]

The problem is false negatives on covid tests. Since you mention the ER I'm assuming this is an antigen test and not PCR. If you're in an open ER/unit I wouldn't push that hard on giving nebs. You could just move the dose up to more than the standard 2 puffs if you feel like they need more albuterol but there's good clinical data comparing efficacy of MDIs with spacers to nebulizers and the outcomes are similar.

 

[bingbongbink]

The problem is false negatives on covid tests. Since you mention the ER I'm assuming this is an antigen test and not PCR. If you're in an open ER/unit I wouldn't push that hard on giving nebs. You could just move the dose up to more than the standard 2 puffs if you feel like they need more albuterol but there's good clinical data comparing efficacy of MDIs with spacers to nebulizers and the outcomes are similar.

Would you be able to link me the data pls?

 

[bingbongbink]

It is an irrational fear if the patient is definitely covid negative

That said, spacers with the MDI work well and might even be better at depositing drug than a nebuliser

Thats true

Nebulizers just make it a whole lot easier for patients

 

[Bobblehead]

I would recommend you review the article "Delivery of inhaled medication in adults" in Uptodate and read the section specifically about covid-19 implications and decide for yourself what works best for your particular institution.