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

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 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

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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.

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