How to provide Aerosolized Treatments for Asthma and COPD patients in the post-COVID-19 era.

About the Author  - Marlon Gilbert, M.D.
About the Author - Marlon Gilbert, M.D.

Dr. Gilbert graduated from the Medical School of the University of the Witwatersrand (WITS) in Johannesburg, South Africa. He completed his internship at Groote Schuur Hospital in Cape Town and then practiced emergency medicine in the United Kingdom. He also completed Family Medicine at Jackson Memorial Hospital in Miami, FL, where he served as the Chief Resident in Family Medicine. He was presented the Chairman’s Award for the best resident in recognition of demonstrated excellence and outstanding academic performance.

It’s safe to say that COVID has changed the landscape of aerosols in a similar way that AIDS changed the landscape for contact precautions.

How? As you know, in the medical world, universal contact precautions calls for gloves when contacting all patients. This concept is now being applied to aerosols.

The question is…

What precautions make sense for all aerosol-related treatments going forward?

Captain Shane Beck says that there is no reason for us to keep rebreathing patient’s aerosols and potentialy endangering ourselves during aerosol generating procedures, a.k.a. AGP’s. He feels that similar precautions, with filters should now apply to all aerosols generating procedures. In short: universal aerosol precautions.

But before we look into how to do that, let’s look at the history of aerosolized medication to understand its evolution.

Aerosolized medications have been around for over 200 years and their delivery has been refined from atomization to jet nebulizers and more recently to vibrating mesh nebulizers.

The goal is simply to deliver fine mist particles, aerosols, into the depths of the lungs. This lung-targeted therapy allows the fine airways, the bronchioles, to receive the intended medication directly and this, therefore, avoids requiring this medication to be delivered systemically.  

A comparison of historical atomizer vs. modern day nebulizer
A comparison of historical atomizer vs. modern day nebulizer

Nowadays, the Center of Disease Control (CDC) refers to AGPs collectively applying to the following procedures:

  • open suctioning of airways
  • sputum induction
  • cardiopulmonary resuscitation
  • endotracheal intubation and extubation
  • non-invasive ventilation (e.g., BiPAP, CPAP)
  • bronchoscopy
  • manual ventilation
  • nebulizer administration
  • high flow O2 delivery

Prior to COVID-19, physicians had steered away from systemic medications such as terbutaline and epinephrine because of the side effects of tachycardia and hypertension. These medications were reserved as an adjunct for status asthmaticus. However, when COVID-19 started, aerosols and therefore aerosolized medications were removed from many treatment protocols, especially in Emergency Medical Services (EMS), where patients with unknown pathogens were restricted from receiving nebulized treatments such as albuterol due to the confined spaces of the ambulance compartments. The concern is that these medication aerosols, which are suspended in the air for up to an hour, could be a vector for pathogens such as COVID-19 and therefore facilitate the transmission of these pathogens.

Similarly, this also affected emergency rooms, ERs. There are over 2 million visits annually to the Emergency Room for each asthma and COPD. Many of these patients arrive at the ER via ambulance with shortness of breath because they have been unable to manage their condition at home, often overusing their metered-dose inhaler, MDI.

Does it then make sense for EMS or the emergency physician to deliver the same treatment that failed the patient at home? Also, are these medications being delivered effectively to the patient’s lungs when they have significant bronchospasm?

an inhaler (MDI) with a spacer optimizes the delivery of medication
Using an inhaler (MDI) with a spacer optimizes the delivery of medication (by allowing normal airflow currents into the depths of the lungs)

Prior to COVID-19, these patients would receive Duonebs, a combination of both nebulized albuterol and Atrovent via a facemask nebulizer or a jet nebulizer. Their turnaround was remarkable. The advantage to a facemask nebulizer is that it provides a continual delivery of these lung-targeted medications and it, therefore, does not require coordination of inspiration and expiration in order to deliver the medications optimally.

Women getting aerosolized treatments at home
An image of a patient using a face mask nebulizer used at home.

These aerosol protocols also affected doctors’ offices. Pulmonologists and allergists used nebulized albuterol to determine patients’ responses to these medications when measuring their pulmonary function tests (PFTs). To obtain the PFT measurements, patients forcefully exhale into a device called a spirometer before and after receiving a nebulized treatment. Spirometry measures the lung’s capacity and it’s ability to fully expire. Because expiration is restricted in asthma and COPD, the PFTs are a valuable tool to these physicians in diagnosing the extent of restriction or spasm and treating their pulmonary patients. When COVID came along, these protocols had to change.  

Aerosoless Medical - Aerosol Precautions-01
Pulmonary function tests are used to determine the patient’s response to nebulized medications.
And the question arose:

Moving forward, should we eliminate nebulized Albuterol and Atrovent from our arsenal when treating shortness of breath whether for asthma, COPD, or acute bronchitis?

The medical field searched for solutions to this dilemma of eliminating aerosols from their treatment and diagnostic protocols. Will we revert back to Epinephrine and terbutaline for emergent asthmatic and COPD conditions? Perhaps the MDI is the solution?  In general, most patients with bronchospasm get by with an MDI. Research has shown that when an MDI is combined with a spacer, the delivery and efficacy of the medication are improved. However, what is the optimal method for treating patients who are not responding sufficiently to their MDIs? Also, since MDI’s are so expensive, especially when used for single-patient use, is this an optimal solution for EMS or ER patients.

Some hospitals were frustrated with the expense of MDIs, or they did not feel nebulized medications were a significant AGP. They actually tried to go back to using nebulizers but they noticed that their respiratory therapists were becoming infected with COVID. 

The American Association for Respiratory Care, AARC, published an article on June 9, 2021 called Pandemic Life | To Nebulize, or Not to Nebulize?

“Like what happened at Sarah Bush Lincoln, it all came to an end in March of last year. But by September, the hospital was once again ready to reinstate the program. Outcomes, however, were troubling.“We began to see an uptick in COVID and were seeing small clusters that we felt the aerosols were contributing to,” said Lyn Harper, MPA, BSRT, RRT, AE-C, director of respiratory care. “So, we once again stopped all nebulizers.”

So what does the future hold for asthmatics, COPD patients, or those with bronchitis? How will we optimally do incentive spirometry testing? How will we treat those patients not responding to MDIs? 

The answer: viral/bacterial filters.

As Captain Shane Beck said when referring to patients with respiratory illnesses: We should put masks or filters on every single patient. “ He is referring to aerosol-generating procedures (AGPs). Captain Beck says, “That should be our standard for the future going forward.“ We should not be rebreathing the patient’s exhaled pathogens! 

viral/bacterial filter by itself
An image of viral/bacterial filter by itself
Filter on the lines of a vented patient
Filter on the lines of a vented patient
Facemask Nebulizer with filters vs. Ambubag with filter between the ETT Tube
Facemask Nebulizer with filters vs. Ambubag with filter between the ETT Tube
The takeaway?

The awareness of aerosols has forever changed.

The medical community has adapted its newfound respect for aerosols and the movement towards viral/bacterial filters for all AGPs is becoming universal, otherwise known as “Standard of Care.” Universal aerosol precautions are here to stay.