Nebulizer use in the Long-Term Care Setting

To use a nebulizer or not to use a nebulizer, that is the question! 

The recent past- 

During Covid, Long Term Care (LTC) clinical staff often switched residents from a nebulizer treatment to a metered-dose inhaler with a dedicated spacer. The rationale being that we would be reducing infectious respiratory aerosols. Now we are past the Covid Pandemic yet many of our residents remain on inhalers when they might be better served with a nebulizer treatment.  

Why the switch- 

The recommendation for the switch came from various sources but one source could be found on the MN Dept of Health website which has since been retired. The recommendations from the website included considerations to minimize transmission risk from nebulizers. This included the suggestion of utilizing a metered-dose inhaler with a dedicated spacer to reduce residents and staff exposure to infection. The document also included identification of Aerosol Generating Procedures or AGPs and considerations to minimize transmission risks.  

So where are we now- 

In a nutshell, residents with Asthma and COPD are less likely to tolerate inhalers. In fact, an inhaler often triggers coughing which can increase the risk for exposure to respiratory infections. It is imperative that we assess each resident individually and provide the best treatment possible. During the peak of Covid facilities often resorted understandably to removing almost all the nebulizer treatments which was not the intention of CDC or the Mn Dept of Health.  

What do we do now- 

If SARS or Covid infection is not suspected in a resident presenting for care (based on symptom and exposure history) the health care professional should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis).  

For a resident with suspected or confirmed COVID staff should wear all PPE as indicated per the CDC guidance. And as always we close the door while administering the treatment not only for privacy but also for containment.  

Facilities should determine if they have any Aerosol Generating Procedures and have a policy that guides the staff when performing these procedures. An example would be open suctioning of airways, CPR and manual ventilation and CPAP/BIPAP. Guiding staff on what PPE should be utilized is key.  A reference tool for this can be found at cdc.gov Respiratory Virus Toolkit. 

In summary- 

Please consider reviewing the residents within your care that are at risk, such as those with Asthma and COPD and assure that an individualized assessment is updated. It is important that if the resident would benefit from a nebulizer treatment regime that they be allowed to have a nebulizer treatment. If there is a concern with a SARS or Covid infection, we will utilize Transmission Based Precautions which is what we are already doing.  We are back to a new normal. I hope this clears up some of the confusion and removes the barriers to providing nebulizer treatments for those in need. 

Lynn Fossen RN, VP | Advanced Health Institute