Prevention of contaminated aerosol and the transmission during nebulized therapy in hospital settings: a systematic review

Published: 9 September 2024
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Inhalation nebulization therapy is important for administering medications to patients in aerosolized form. However, there are persistent apprehensions in healthcare settings regarding aerosol contamination because of the significant infection risk. Despite rigorous adherence to established hospital protocols, concerns about potential contamination and transmission persist, raising considerable apprehension about nosocomial pneumonia. This condition shows the urgent need for implementing highly effective strategies to ensure patient safety during nebulization therapy. Therefore, this study aimed to review current investigations, focusing on interventions to mitigate aerosol contamination and minimize the transmission of contaminated aerosols.
Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this systematic review included an exhaustive analysis of randomized and non-randomized clinical trials as well as, simulated experimental and in vitro studies published in English in the past decade. A meticulous search was conducted across four major databases, namely ScienceDirect, Cumulative Index to Nursing & Allied Health (CINAHL), PubMed, and Scopus. A total of 37 pertinent studies were identified and subjected to rigorous analysis.
The preventive measures include a range of strategies, such as the use of masks by therapists, thorough disinfection of nebulizers, integration of filters, and regular environmental cleaning in the vicinity of the patient.
In conclusion, these multifaceted interventions are significant in preventing the administration of contaminated aerosols and curbing the proliferation of infectious agents in the hospital environment.

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McCarthy SD, González HE, Higgins BD. Future Trends in Nebulized Therapies for Pulmonary Disease. J Pers Med. 2020 May 10;10(2):37. DOI: https://doi.org/10.3390/jpm10020037
Barjaktarevic IZ, Milstone AP. Nebulized Therapies in COPD: Past, Present, and the Future. Int J Chron Obstruct Pulmon Dis. 2020 Jul;Volume 15:1665–77. DOI: https://doi.org/10.2147/COPD.S252435
Matuszak M, Ochowiak M, Włodarczak S, Krupińska A, Doligalski M. State-of-the-art review of the application and development of various methods of aerosol therapy. Int J Pharm. 2022 Feb;614:121432. DOI: https://doi.org/10.1016/j.ijpharm.2021.121432
Harris JC, Collins MS, Huang PH, Schramm CM, Nero T, Yan J, et al. Bacterial Surface Detachment during Nebulization with Contaminated Reusable Home Nebulizers. Brissette CA, editor. Microbiol Spectr. 2022 Feb 23;10(1). DOI: https://doi.org/10.1128/spectrum.02535-21
Reychler G, Vecellio L, Dubus JC. Nebulization: A potential source of SARS-CoV-2 transmission. Respir Med Res. 2020 Nov;78:100778. DOI: https://doi.org/10.1016/j.resmer.2020.100778
Swanson CS, Dhand R, Cao L, Ferris J, Elder CS, He Q. Microbiome-based source identification of microbial contamination in nebulizers used by inpatients. Journal of Hospital Infection. 2022 Apr;122:157–61. DOI: https://doi.org/10.1016/j.jhin.2022.01.008
Elmashae Y, Yermakov M, Frank E, Benjamin M, Maier A, Newman N, et al. Exposure of home-attending healthcare workers to aerosolized medications (simulation study). J Aerosol Sci. 2019 Jul;133:49–55. DOI: https://doi.org/10.1016/j.jaerosci.2019.04.006
Kao CL, Lin CH. A novel mask to prevent aerosol spread during nebulization treatment. Journal of the Formosan Medical Association. 2021 Jan;120(1):769–71. DOI: https://doi.org/10.1016/j.jfma.2020.07.040
Swanson CS, Dhand R, Cao L, Ferris J, Elder CS, He Q. Microbiome-Scale Analysis of Aerosol Facemask Contamination during Nebulization Therapy in the Hospital. Journal of Hospital Infection. 2023 Jan;101890. DOI: https://doi.org/10.1016/j.jhin.2023.01.008
O’Malley CA. Device cleaning and infection control in aerosol therapy. Respir Care. 2015;60(6):917–30. DOI: https://doi.org/10.4187/respcare.03513
Bell J, Alexander L, Carson J, Crossan A, McCaughan J, Mills H, et al. Nebulizer hygiene in cystic fibrosis: evidence-based recommendations. Breathe. 2020 Jun;16(2):190328. DOI: https://doi.org/10.1183/20734735.0328-2019
Burnett E. Effective infection prevention and control: the nurse’s role. Nursing Standard. 2018 Jun;33(4):68–72. DOI: https://doi.org/10.7748/ns.2018.e11171
Russell CD, Koch O, Laurenson IF, O’Shea DT, Sutherland R, Mackintosh CL. Diagnosis and features of hospital-acquired pneumonia: a retrospective cohort study. Journal of Hospital Infection. 2016 Mar;92(3):273–9. DOI: https://doi.org/10.1016/j.jhin.2015.11.013
Aiesh BM, Qashou R, Shemmessian G, Swaileh MW, Abutaha SA, Sabateen A, et al. Nosocomial infections in the surgical intensive care unit: an observational retrospective study from a large tertiary hospital in Palestine. BMC Infect Dis. 2023 Oct 13;23(1):686. DOI: https://doi.org/10.1186/s12879-023-08677-z
Kim BG, Kang M, Lim J, Lee J, Kang D, Kim M, et al. Comprehensive risk assessment for hospital-acquired pneumonia: sociodemographic, clinical, and hospital environmental factors associated with the incidence of hospital-acquired pneumonia. BMC Pulm Med. 2022 Dec 12;22(1):21. DOI: https://doi.org/10.1186/s12890-021-01816-9
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;n71. DOI: https://doi.org/10.1136/bmj.n71
Schiavenato M, Chu F. PICO: What it is and what it is not. Nurse Educ Pract. 2021 Oct 1;56:103194. DOI: https://doi.org/10.1016/j.nepr.2021.103194
MacIntyre CR, Wang Q, Rahman B, Seale H, Ridda I, Gao Z, et al. Efficacy of face masks and respirators in preventing upper respiratory tract bacterial colonization and co-infection in hospital healthcare workers. Prev Med (Baltim). 2014 May;62:1–7. DOI: https://doi.org/10.1016/j.ypmed.2014.01.015
Asadi S, Cappa CD, Barreda S, Wexler AS, Bouvier NM, Ristenpart WD. Efficacy of masks and face coverings in controlling outward aerosol particle emission from expiratory activities. Sci Rep. 2020 Sep 24;10(1):15665. DOI: https://doi.org/10.1038/s41598-020-72798-7
Sterr CM, Nickel IL, Stranzinger C, Nonnenmacher-Winter CI, Günther F. Medical face masks offer self-protection against aerosols: An evaluation using a practical in vitro approach on a dummy head. PLoS One. 2021 Mar 3;16(3):e0248099. DOI: https://doi.org/10.1371/journal.pone.0248099
Armand Q, Whyte HE, Verhoeven P, Grattard F, Leclerc L, Curt N, et al. Impact of medical face mask wear on bacterial filtration efficiency and breathability. Environ Technol Innov. 2022 Nov;28:102897. DOI: https://doi.org/10.1016/j.eti.2022.102897
Liu J, Hao M, Chen S, Yang Y, Li J, Mei Q, et al. Numerical evaluation of face masks for prevention of COVID-19 airborne transmission. Environmental Science and Pollution Research. 2022 Jun 9;29(29):44939–53. DOI: https://doi.org/10.1007/s11356-022-18587-3
Weng CH, Kao CL, Chiu PW, Huang SP, Kuo YS, Lin YY, et al. A full-face mask for protection against respiratory infections. Biomed Eng Online. 2022 Sep 5;21(1):62. DOI: https://doi.org/10.1186/s12938-022-01027-1
Han Z, Wang L, Liu Y, Chan T, Shi Z, Yu M. How do three-layer surgical masks prevent SARS-CoV-2 aerosol transmission? Sep Purif Technol. 2023 Jun;314:123574. DOI: https://doi.org/10.1016/j.seppur.2023.123574
Towle D, Callan DA, Farrel PA, Egan ME, Murray TS. Baby bottle steam sterilizers disinfect home nebulizers inoculated with bacterial respiratory pathogens. Journal of Cystic Fibrosis. 2013 Sep;12(5):512–6. DOI: https://doi.org/10.1016/j.jcf.2012.11.013
Towle D, Callan DA, Lamprea C, Murray TS. Baby bottle steam sterilizers for disinfecting home nebulizers inoculated with non-tuberculous mycobacteria. Journal of Hospital Infection. 2016;92(3):222–5. DOI: https://doi.org/10.1016/j.jhin.2015.08.030
Moore J, Millar B. Susceptibility of the Mycobacterium abscessus complex to drying: Implications for nebulizer hygiene in patients with cystic fibrosis. Int J Mycobacteriol. 2020;9(2):173–5. DOI: https://doi.org/10.4103/ijmy.ijmy_62_20
Lopes MS, Ferreira JRF, da Silva KB, de Oliveira Bacelar Simplício I, de Lima CJ, Fernandes AB. Disinfection of corrugated tubing by ozone and ultrasound in mechanically ventilated tracheostomized patients. Journal of Hospital Infection. 2015 Aug;90(4):304–9. DOI: https://doi.org/10.1016/j.jhin.2015.03.004
Moore JE, Moore RE, Bell J, Millar BC. Importance of nebulizer drying for patients with cystic fibrosis. Respir Care. 2020;65(10):1444–50. DOI: https://doi.org/10.4187/respcare.07362
Hohenwarter K, Prammer W, Aichinger W, Reychler G. An evaluation of different steam disinfection protocols for cystic fibrosis nebulizers. Journal of Cystic Fibrosis. 2016;15(1):78–84. DOI: https://doi.org/10.1016/j.jcf.2015.07.005
Moore JE, Millar BC. Susceptibility of Staphylococcus aureus (MSSA and MRSA) to drying: implications for nebulizer hygiene in patients with cystic fibrosis. Journal of Hospital Infection. 2020 Jun;105(2):366–7. DOI: https://doi.org/10.1016/j.jhin.2020.04.015
da Costa Luciano C, Olson N, Tipple AFV, Alfa M. Evaluation of the ability of different detergents and disinfectants to remove and kill organisms in traditional biofilm. Am J Infect Control. 2016 Nov;44(11):e243–9. DOI: https://doi.org/10.1016/j.ajic.2016.03.040
Rodney J, Ojano‐Dirain CP, Antonelli PJ, Silva RC. Effect of repeated tracheostomy tube reprocessing on biofilm formation. Laryngoscope. 2016 Apr 12;126(4):996–9. DOI: https://doi.org/10.1002/lary.25473
Towle D, Baker V, Schramm C, O’Brien M, Collins MS, Feinn R, et al. Ozone disinfection of home nebulizers effectively kills common cystic fibrosis bacterial pathogens. Pediatr Pulmonol. 2018;53(5):599–604. DOI: https://doi.org/10.1002/ppul.23990
Moore J, Millar B. Effect of Ultraviolet-c (UVc) light and ozone on the survival of Mycobacterium abscessus complex organisms associated with cystic fibrosis. Int J Mycobacteriol. 2022;11(3):256. DOI: https://doi.org/10.4103/ijmy.ijmy_87_22
Ibáñez-Cervantes G, Cruz-Cruz C, Durán-Manuel EM, Loyola-Cruz MÁ, Cureño-Díaz MA, Castro-Escarpulli G, et al. Disinfection efficacy of ozone on ESKAPE bacteria biofilms: Potential use in difficult-to-access medical devices. Am J Infect Control [Internet]. 2023 Jan;51(1):11–7. DOI: https://doi.org/10.1016/j.ajic.2022.03.037
Pineau L, Radix C, Weber DJ. Comparison of the sporicidal activity of a UV disinfection process with three FDA-cleared sterilants. Am J Infect Control. 2022;50(12):1316–21. DOI: https://doi.org/10.1016/j.ajic.2022.02.027
Hu HC, Liu HC, Chen YH, Huang CC, Wan GH, Chou LT, et al. The impact of aerosolized mucolytic agents on the airflow resistance of bacterial filters used in mechanical ventilation. Journal of the Formosan Medical Association. 2015 Aug;114(8):717–21. DOI: https://doi.org/10.1016/j.jfma.2013.06.010
Mac Giolla Eain M, Cahill R, MacLoughlin R, Nolan K. Aerosol release, distribution, and prevention during aerosol therapy: a simulated model for infection control. Drug Deliv. 2022 Dec 31;29(1):10–7. DOI: https://doi.org/10.1080/10717544.2021.2015482
Sugget JA, Nagel M. Efficiency of a nebulizer filter kit to prevent environmental contamination during nebulizer therapy. Chest. 2022 Oct;162(4):A2472. DOI: https://doi.org/10.1016/j.chest.2022.08.2024
Phu HT, Park Y, Andrews AJ, Marabella I, Abraham A, Mimmack R, et al. Design and evaluation of a portable negative pressure hood with HEPA filtration to protect healthcare workers treating patients with transmissible respiratory infections. Am J Infect Control. 2020;48(10):1237–43. DOI: https://doi.org/10.1016/j.ajic.2020.06.203
Franke G, Knobling B, Brill FH, Becker B, Klupp EM, Belmar Campos C, et al. An automated room disinfection system using ozone is highly active against surrogates for SARS-CoV-2. Journal of Hospital Infection. 2021 Jun;112:108–13. DOI: https://doi.org/10.1016/j.jhin.2021.04.007
Trinh VM, Yuan MH, Chen YH, Wu CY, Kang SC, Chiang PC, et al. Chlorine dioxide gas generation using a rotating packed bed for air disinfection in a hospital. J Clean Prod. 2021;320:128885. DOI: https://doi.org/10.1016/j.jclepro.2021.128885
Xia T, Guo K, Pan Y, An Y, Chen C. Temporal and spatial far-ultraviolet disinfection of exhaled bioaerosols in a mechanically ventilated space. J Hazard Mater. 2022 Aug;436:129241. DOI: https://doi.org/10.1016/j.jhazmat.2022.129241
Nunayon SS, Wang M, Zhang HH, Lai ACK. Evaluating the efficacy of a rotating upper-room UVC-LED irradiation device in inactivating aerosolized Escherichia coli under different disinfection ranges, air mixing, and irradiation conditions. J Hazard Mater. 2022 Oct;440:129791. DOI: https://doi.org/10.1016/j.jhazmat.2022.129791
Wang MH, Zhang HH, Chan CK, Lee PKH, Lai ACK. Experimental study of the disinfection performance of a 222-nm Far-UVC upper-room system on airborne microorganisms in a full-scale chamber. Build Environ. 2023 May;236:110260. DOI: https://doi.org/10.1016/j.buildenv.2023.110260
Lu YH, Wu H, Zhang HH, Li WS, Lai ACK. Synergistic disinfection of aerosolized bacteria and bacteriophage by far-UVC (222-nm) and negative air ions. J Hazard Mater. 2023 Jan;441:129876. DOI: https://doi.org/10.1016/j.jhazmat.2022.129876
Sottani C, Favorido Barraza G, Frigerio F, Corica G, Robustelli della Cuna FS, Cottica D, et al. Effectiveness of a combined UV-C and ozone treatment in reducing healthcare-associated infections in hospital facilities. Journal of Hospital Infection. 2023 Sep;139:207–16. DOI: https://doi.org/10.1016/j.jhin.2023.06.029
Swarnakar R, Gupta N, Halder I, Khilnani G. Guidance for nebulization during the COVID-19 pandemic. Lung India. 2021;38(7):86. DOI: https://doi.org/10.4103/lungindia.lungindia_681_20
Zhang M, Zheng H, Wang J. Strategy of using personal protective equipment during aerosol-generating medical procedures with COVID-19. J Clin Anesth. 2020 Nov;66:109911. DOI: https://doi.org/10.1016/j.jclinane.2020.109911
Driessche K Vanden, Hens N, Tilley P, Quon BS, Chilvers MA, de Groot R, et al. Surgical Masks Reduce Airborne Spread of Pseudomonas aeruginosa in Colonized Patients with Cystic Fibrosis. Am J Respir Crit Care Med. 2015 Oct 1;192(7):897–9. DOI: https://doi.org/10.1164/rccm.201503-0481LE
Martinelli L, Kopilaš V, Vidmar M, Heavin C, Machado H, Todorović Z, et al. Face Masks During the COVID-19 Pandemic: A Simple Protection Tool With Many Meanings. Front Public Health. 2021 Jan 13;8. DOI: https://doi.org/10.3389/fpubh.2020.606635
Katiyar SK, Gaur SN, Solanki RN, Sarangdhar N, Suri JC, Kumar R, et al. Indian Guidelines on Nebulization Therapy. Indian Journal of Tuberculosis. 2022;69:S1–191.
Central for Disease Control and Prevention (CDC). Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1–36.
CDC. Ventilator-associated Pneumonia (VAP). 2023 [cited 2023 Aug 12]. Ventilator-associated Pneumonia Basics. Available from: https://www.cdc.gov/ventilator-associated-pneumonia/about/index.html.
Collins MS, O’Brien M, Schramm CM, Murray TS. Repeated hot water and steam disinfection of Pari LC Plus® nebulizers alter nebulizer output. Journal of Cystic Fibrosis. 2019;18(2):233–5. DOI: https://doi.org/10.1016/j.jcf.2018.08.005
Manor E, Gur M, Geffen Y, Bentur L. Cleaning and infection control of airway clearance devices used by CF patients. Chron Respir Dis. 2017;14(4):370–6. DOI: https://doi.org/10.1177/1479972317707652
Caskey S, Moore JE, Rendall JC. In vitro activity of seven hospital biocides against Mycobacterium abscessus: Implications for patients with cystic fibrosis. Int J Mycobacteriol. 2018;7(1):45–7. DOI: https://doi.org/10.4103/ijmy.ijmy_197_17
Collins MS, Harris J, Murray T. Efficacy of Thermal and Chemical Methods of Nebulizer Disinfection of CF Pathogens. In: Cystic fibrosis. European Respiratory Society; 2019. p. PA981. DOI: https://doi.org/10.1183/13993003.congress-2019.PA981
Hutauruk SM, Hermani B, Monasari P. Role of chlorhexidine on tracheostomy cannula decontamination in relation to the growth of Biofilm-Forming Bacteria Colony- a randomized controlled trial study. Annals of Medicine and Surgery. 2021;67(June):102491. DOI: https://doi.org/10.1016/j.amsu.2021.102491
Epelle EI, Macfarlane A, Cusack M, Burns A, Thissera B, Mackay W, et al. Bacterial and fungal disinfection via ozonation in air. J Microbiol Methods. 2022 Mar;194:106431. DOI: https://doi.org/10.1016/j.mimet.2022.106431
Cristiano L. Could ozone be an effective disinfection measure against the novel coronavirus (SARS-CoV-2)? J Prev Med Hyg. 2020 Oct 6 [cited 2023 Oct 18];61(3): E301.
Khan M, McDonald M, Mundada K, Willcox M. Efficacy of Ultraviolet Radiations against Coronavirus, Bacteria, Fungi, Fungal Spores and Biofilm. Hygiene. 2022 Aug 12;2(3):120–31. DOI: https://doi.org/10.3390/hygiene2030010
Van Heerden L, Van Aswegen H, Van Vuuren S, Roos R, Duse A. Contamination of nebulizers and surrounding air at the bedside of mechanically ventilated patients. Southern African Journal of Critical Care. 2017;33(1):23–7.
Liu Z, Xiao X, Jiang C, Wang Y, He J. Assessment of the air disinfection effect of low-concentration ozone in a closed environment. Build Environ. 2023 Oct;244:110747. DOI: https://doi.org/10.1016/j.buildenv.2023.110747
Alebrahim MA, Bakkar MM, Al Darayseh A, Msameh A, Jarrar D, Aljabari S, et al. Awareness and Knowledge of the Effect of Ultraviolet (UV) Radiation on the Eyes and the Relevant Protective Practices: A Cross-Sectional Study from Jordan. Healthcare. 2022 Nov 30;10(12):2414. DOI: https://doi.org/10.3390/healthcare10122414
Grignani E, Mansi A, Cabella R, Castellano P, Tirabasso A, Sisto R, et al. Safe and Effective Use of Ozone as Air and Surface Disinfectant in the Conjuncture of Covid-19. Gases. 2020 Dec 24;1(1):19–32. DOI: https://doi.org/10.3390/gases1010002
Adanur S, Jayswal A. Filtration mechanisms and manufacturing methods of face masks: An overview. Journal of Industrial Textiles. 2022 Jun 22;51(3_suppl):3683S-3717S. DOI: https://doi.org/10.1177/1528083720980169
Rennert-May E, Conly J, Leal J, Smith S, Manns B. Economic evaluations and their use in infection prevention and control: a narrative review. Antimicrob Resist Infect Control. 2018 Feb 27;7(1):31. DOI: https://doi.org/10.1186/s13756-018-0327-z

How to Cite

Ariningpraja, R. T., Widyawati, I. Y., & Azizah, N. (2024). Prevention of contaminated aerosol and the transmission during nebulized therapy in hospital settings: a systematic review. Healthcare in Low-Resource Settings. https://doi.org/10.4081/hls.2024.13044