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      Nebulized Therapy in the COVID-19 Era: The Right Tool for the Right Patient [Letter]

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      International Journal of Chronic Obstructive Pulmonary Disease

      Dove

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          Abstract

          Dear editor I read with great interest the relatively recent editorial by Dr Richard Russell entitled “COVID-19 and COPD: A Personal Reflection”.1 I especially focused on the line “Anxiety can drive malbehavior.” Indeed, we healthcare personnel treating patients with respiratory diseases may not be completely absolved of anxiety-driven malbehavior in this COVID-19 world, as we try to come to grips with an indefatigable virus and wrap our heads around ways to slow it down and stop it. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has brought into sharp focus how healthcare personnel must approach the treatment of patients with respiratory disease. While we wait for the clinical or quantitative evidence necessary to establish true best practices, there is a concern that healthcare personnel, patients, and healthcare systems are prioritizing one form of therapy over another based on assumptions or partial information rather than evidence. This is certainly an issue that requires further consideration. Consider the large-scale dispensing of albuterol metered-dose inhalers (MDIs) to hospitalized patients with COVID-19, which has resulted in severe shortages of albuterol MDIs in some parts of the United States.2 This is not a supply chain problem but rather an acute crisis caused by the sharp increase in MDI use driven by the concern that nebulizers used by hospitalized patients with COVID-19 could potentially spread the SARS-CoV-2 virus.3 This concern could potentially extend to home use of nebulizers. But is this an appropriate use of now-limited resources, such as MDIs, or is this a reflexive reaction to a perceived risk with aerosol-generating procedures? Does the answer depend on the setting of care? Unfortunately, there is no precedent to guide the treatment of patients with respiratory disease in the current situation because experience from previous episodes of mass infection do not appear to be scalable to the worldwide SARS-CoV-2 pandemic. At a time when public health information is in a state of rapid flux, rather than using a one-size-fits-all policy, the more sensible approach would be to use a right-tool-for-the-right-patient strategy based on what we know. Thus, nebulizers should remain the preferred option for patients who require that treatment, especially in light of the severe shortage of MDIs. This approach does not conflict with recent COVID-19 guidance and can serve as an example for encouraging best practices even after the pandemic. The National Institute for Health and Care Excellence (NICE) and the UK Government guidance from the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) recommend the continued use of nebulizers because the aerosols produced by them are generated from fluid within the nebulizer chamber that does not carry patient-derived viral particles. If a particle in the aerosol coalesces with contaminated mucous membrane, it ceases to be airborne and therefore will not be aerosolized.4 The Global Initiative for Chronic Obstructive Lung Disease advises that patients with chronic obstructive pulmonary disease maintain their regular therapy and recommends nebulizers for those who need them and MDIs for patients who are suitable for them.5 At present, only a few studies have investigated the risk of aerosol-generating treatments spreading any type of coronavirus. A 2012 assessment of three cohort studies investigating the transmission of coronavirus to healthcare personnel during the 2002–2003 SARS-CoV outbreaks found no significantly elevated risk of SARS-CoV transmission to healthcare workers caring for patients undergoing nebulizer treatment.6 A recent article by Dr Arzu Ari indicates that, while unnecessary aerosol therapy should continue to be avoided, the risk of viral transmission can be minimized with basic precautions.7 Although limited, these studies suggest that there is no compelling reason to alter aerosol modality for patients with established nebulizer-based regimens. Guidance for the treatment of patients with respiratory disease during the SARS-CoV-2 pandemic is rapidly evolving as new details of viral transmission are being elucidated. At present, data on whether nebulized treatment represent an infection transmission risk are limited. Moving forward, it will be important to follow evidence-based treatment procedures using the right-tool-for-the-right-patient approach and to not overreact based on assumptions, which could lead to future shortages of medical resources as well as possible suboptimal outcomes related to medication delivery and patient-related factors.

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          Practical strategies for a safe and effective delivery of aerosolized medications to patients with COVID-19

           Arzu Ari (2020)
          The COVID-19, the disease caused by a novel coronavirus and named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread rapidly across the globe. It has caused outbreaks of illness due to person-to-person transmission of the virus mainly via close contacts and droplets produced by an infected person's cough or sneeze. Exhaled droplets from infected patients with COVID-19 can be inhaled into the lungs and leads to respiratory illness such as pneumonia and acute respiratory distress syndrome. Although aerosol therapy is a mainstay procedure used to treat pulmonary diseases at home and healthcare settings, it has a potential for fugitive emissions during therapy due to the generation of aerosols and droplets as a source of respiratory pathogens. Delivering aerosolized medications to patients with COVID-19 can aggravate the spread of the novel coronavirus. This has been a real concern for caregivers and healthcare professionals who are susceptible to unintended inhalation of fugitive emissions during therapy. Due to a scarcity of information in this area of clinical practice, the purpose of this paper is to explain how to deliver aerosolized medications to mild-, sub-intensive, and intensive patients with COVID-19 and how to protect staff from exposure to exhaled droplets during aerosol therapy.
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            Covid-19 and COPD: A Personal Reflection

            As China seems to be emerging from their COVID epidemic and the rest of the world is plunged headlong into their own perhaps I can be forgiven by the readers of this journal for a moment or two of reflection and even self-indulgence. It is a huge privilege to be the editor of the International Journal of COPD and this enables me to keep abreast of all current COPD research. Loyal readers will know that we accept a catholic spread of research and are very much patient-focused. As editor, I have maintained as a principle that the research we published must be potentially translatable. I am also a committed front-line clinician and clinical researcher. And so, with these three perspectives, I have been able to reflect on the current COVID-19 crisis and what this means to our patients, our colleagues and our families. Personally, I have been concerned both for myself and my family. This is a potentially serious infection and world-wide many good health-care practitioners have been killed by it. So, what have I learnt and what can I pass on? We are being overwhelmed with data, rapidly published research of variable quality, providence and sometimes the potential to change practice. However, not much of this is at all applicable or helpful at the two levels that matter: at the whole healthcare economy-level or at the individual patient level. Indeed, I have felt that on occasion being able to shut out a lot of this noise would have been helpful. It is wonderful that information can flow so rapidly around the world and that we can learn from the terrible experiences that colleagues in China and Italy have been facing. But this must be synthesised into something practical for your health-care setting. A lack of appropriate PPE may be much more important in an area than which combination of anti-viral is best. Anxiety can drive malbehavior. It must be one of our primary goals at this time to reduce anxiety in our existing patients. My COPD patients are very afraid and believe that they are especially vulnerable and are about to die. This is not necessarily the case. It is essential that we help our patients and answer any question that they have in a clear evidence based and non-judgmental manner. I have fielded many questions and hopefully have left my patients feeling reassured and also informed. Yes, many will get this infection, but most will get relatively mild disease which will not lead to complications or a high risk of mortality. We know that patients want reassurance that the medical profession will look after them however the continuous and instantaneous news streams can lead to them feeling increasingly isolated and vulnerable. We have known that this isolation was a significant issue in COPD patients before the COVID-19 and now is of even more importance. As COPD and Respiratory specialists, it is clear that we need to help lead the efforts of our health-care systems against COVID-19 and any future novel viral infections. Our intensivist colleagues will need support from us at an early stage to ensure that the correct patients get the treatment that they need in a timely fashion. Most patients will be able to stay at home but may need the support of primary care respiratory services. Some will need hospital admission to manage the significant symptoms that this virus brings with it. And finally, we will need to help make early decisions about escalation plans and appropriate ceilings for care, especially for those living with COPD. So, I wish you all, my colleagues, friends and the Respiratory Community the very best at this troubled time. I hope you and your families stay safe and well and are able to deliver the highest possible care with compassion to your patients. When this is over we will be able to further reflect on what happened and how we can be better at delivering care now as well as being better prepared for future challenges.
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              Author and article information

              Journal
              Int J Chron Obstruct Pulmon Dis
              Int J Chron Obstruct Pulmon Dis
              copd
              copd
              International Journal of Chronic Obstructive Pulmonary Disease
              Dove
              1176-9106
              1178-2005
              07 September 2020
              2020
              : 15
              : 2101-2102
              Affiliations
              [1 ]Department of Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine , Kalamazoo, MI 49008, USA
              Author notes
              Correspondence: Michael W Hess Department of Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine , 1000 Oakland Drive, Kalamazoo, MI49008, USA Email michael.hess@med.wmich.edu
              Article
              272382
              10.2147/COPD.S272382
              7489944
              © 2020 Hess.

              This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

              Page count
              Figures: 0, References: 7, Pages: 2
              Categories
              Letter

              Respiratory medicine

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