Risk for transmission of viral infection during treatment with nebuliser or high-flow nasal cannula

Viral infections caused by SARS-CoV-2, SARS-CoV-1 or MERS-CoV can lead to severe respiratory failure and the need for hospital care. There is a concern that treatment with nebuliser or high-flow nasal cannula may present an increased risk for transmission of infectious diseases trough the production and spread of aerosols.

Reading time approx. 12 minutes Published: Publication type:

SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Published: Report no: ut202022 Registration no: SBU 2020/449

Question

What scientific studies are there on 1) risk for transmission of SARS-CoV-2, SARS-CoV-1 or MERS-CoV infections and 2) spread of aerosols during treatment with nebuliser or high-flow nasal cannula? 

Method

SBU’s Enquiry Service identifies and summarizes systematic reviews or scientific studies which answer specific questions posed by decision makers and health care personnel. For this question, PubMed, Embase, Cinahl and Cochrane Library were systematically searched in April 29, 2020, and supplemented by manual searching of reference lists. Records relevant to the question posed were identified and assessed for risk of bias by two independent persons. The identified primary studies were assessed for risk of bias using translated versions of RoB-2 [1] and ROBINS-I [2]. Studies without control groups were assessed for methodological concerns through a customized checklist. The results of the identified studies were not synthesized or assessed for certainty of evidence.

Identified literature

One systematic review and five primary studies were identified that investigated risk for transmission of SARS-CoV-2, SARS-CoV-1 or MERS-CoV in association to treatment with nebuliser [3–8]. All primary studies were judged to have a high risk of bias from confounders and retrospective data collection. No study was identified that investigated risk of transmission in association to treatment with high-flow nasal cannula.

17 studies were identified that investigated spread of aerosols from nebulisers or high-flow nasal cannulas. 7 of the studies were performed in a hospital environment involving patients or healthy persons [9–15], and 10 of the studies were experimental model studies involving human simulators [16–25]. The studies were heterogenous regarding outcome, method of measuring and distance to the source. Only clinical studies were assessed for risk of bias.

References

  1. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. Bmj 2019;366:l4898.
  2. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016;355:i4919.
  3. Heinzerling A, Stuckey MJ, Scheuer T, Xu K, Perkins KM, Resseger H, et al. Transmission of COVID-19 to health care personnel during exposures to a hospitalized patient - Solano County, California, February 2020. MMWR Morb Mortal Wkly Rep 2020;69:472-6.
  4. Loeb M, McGeer A, Henry B, Ofner M, Rose D, Hlywka T, et al. SARS among critical care nurses, Toronto. Emerg Infect Dis 2004;10:251-5.
  5. Raboud J, Shigayeva A, McGeer A, Bontovics E, Chapman M, Gravel D, et al. Risk factors for SARS transmission from patients requiring intubation: a multicentre investigation in Toronto, Canada. PLoS One 2010;5:e10717.
  6. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS ONE 2012;7.
  7. Wong TW, Lee CK, Tam W, Lau JT, Yu TS, Lui SF, et al. Cluster of SARS among medical students exposed to single patient, Hong Kong. Emerg Infect Dis 2004;10:269-76.
  8. Yu IT, Zhan HX, Tsoi KK, Yuk LC, Siu WL, Xiao PT, et al. Why did outbreaks of severe acute respiratory syndrome occur in some hospital wards but not in others? Clin Infect Dis 2007;44:1017-25.
  9. He C, Mackay IM, Ramsay K, Liang Z, Kidd T, Knibbs LD, et al. Particle and bioaerosol characteristics in a paediatric intensive care unit. Environment International 2017;107:89-99.
  10. Jones AM, Govan JR, Doherty CJ, Dodd ME, Isalska BJ, Stanbridge TN, et al. Identification of airborne dissemination of epidemic multiresistant strains of Pseudomonas aeruginosa at a CF centre during a cross infection outbreak. Thorax 2003;58:525-7.
  11. Leung CCH, Joynt GM, Gomersall CD, Wong WT, Lee A, Ling L, et al. Comparison of high-flow nasal cannula versus oxygen face mask for environmental bacterial contamination in critically ill pneumonia patients: a randomized controlled crossover trial. J Hosp Infect 2019;101:84-7.
  12. O'Neil CA, Li J, Leavey A, Wang Y, Hink M, Wallace M, et al. Characterization of aerosols generated during patient care activities. Clinical Infectious Diseases 2017;65:1342-1348.
  13. Simonds AK, Hanak A, Chatwin M, Morrell M, Hall A, Parker KH, et al. Evaluation of droplet dispersion during non-invasive ventilation, oxygen therapy, nebuliser treatment and chest physiotherapy in clinical practice: implications for management of pandemic influenza and other airborne infections. Health technology assessment (Winchester, England) 2010;14:131-172.
  14. Thompson K, Thomson G, Mittal H, Parks S, Dove B, Speight S, et al. Transmission of influenza to health-care workers in intensive care units - Could Aerosol generating procedures play a role? Journal of Hospital Infection 2010;76:S5.
  15. Wan GH, Tsai YH, Wu YK, Tsao KC. A large-volume nebulizer would not be an infectious source for severe acute respiratory syndrome. Infect Control Hosp Epidemiol 2004;25:1113-5.
  16. Bennett G, O'Toole C, Joyce M, McGrath J, Byrne M, MacLoughlin R. Effect of tidal volume on fugitive emissions during mechanical ventilation. Eur Respir J 2018;52.
  17. Hui DS, Chow BK, Chu LCY, Ng SS, Hall SD, Gin T, et al. Exhaled air and aerosolized droplet dispersion during application of a jet nebulizer. Chest 2009;135:648-54.
  18. Leonard S, Atwood CW, Walsh BK, DeBellis RJ, Dungan GC, Strasser W, et al. Preliminary Findings of Control of Dispersion of Aerosols and Droplets during High Velocity Nasal Insufflation Therapy Using a Simple Surgical Mask: Implications for High Flow Nasal Cannula. Chest 2020.
  19. McGrath JA, O'Sullivan A, Bennett G, O'Toole C, Joyce M, Byrne MA, et al. Investigation of the Quantity of Exhaled Aerosols Released into the Environment during Nebulisation. Pharmaceutics 2019;11.
  20. McGrath JA, O'Toole C, Bennett G, Joyce M, Byrne MA, MacLoughlin R. Investigation of Fugitive Aerosols Released into the Environment during High-Flow Therapy. Pharmaceutics 2019;11.
  21. Hui DS, Chan MT, Chow B. Aerosol dispersion during various respiratory therapies: a risk assessment model of nosocomial infection to health care workers. Hong Kong Med J 2014;20 Suppl 4:9-13.
  22. Ari A FJ, Pilbeam S. Secondhand aerosol exposure during mechanical ventilation with and without expiratory filters: An in-vitro study. Ind J Resp Care 2016;5:677-83.
  23. Hui DS, Chow BK, Lo T, Tsang OTY, Ko FW, Ng SS, et al. Exhaled air dispersion during high-flow nasal cannula therapy versus CPAP via different masks. Eur Respir J 2019;53.
  24. Kotoda M, Hishiyama S, Mitsui K, Tanikawa T, Morikawa S, Takamino A, et al. Assessment of the potential for pathogen dispersal during high-flow nasal therapy. J Hosp Infect 2020;104:534-7.
  25. Hui DS, Chow BK, Chu L, Ng SS, Lai ST, Gin T, et al. Exhaled air dispersion and removal is influenced by isolation room size and ventilation settings during oxygen delivery via nasal cannula. Respirology 2011;16:1005-13.

Literature search

MedLine via Ovid 200429 
High Flow Nasal Cannula
Search terms Items found
Intervention:
1. (high flow adj4 (nasal or oxygen or cannula)).ab,kf,ti. 1 695
2. HFNC.ab,kf,ti. 453
3. HFNOT.ab,kf,ti. 3
4. 1 or 2 or 3 1 705
5. “Nebulizers and Vaporizers”/ 9 198
6. (nebulis* or nebuliz*).ab.kf,ti. 10 412
7. 5 or 6 16 153
Outcome:
8. ((aerosol* or bioaerosol*) adj4 (generat* or fugitive or dispers* or exhal* or secondary)).ab,kf,ti. 4 453
9. Aerosols/ 30 082
10. aerosol*.ab,kf,ti. 44 501
11. bioaerosol*.ab,kf,ti. 1 457
12. 9 or 10 or 11 55 001
13. Exp Disease Transmission, Infectious/ 67 498
14. Infection Control/ 23 535
15. Exp Cross Infection/ 58 766
16. ((disease or virus) adj3 transmission).ab.kf.ti. 19 861
17. infection control.ab,kf,ti. 20 287
18. (hospital adj2 (acquired or infection)).ab.kf.ti. 12 975
19. nosocomial.ab,kf,ti. 30 204
20. (infection adj3 risk*).ab, kf, ti. 40 440
21. (virus adj3 survival).ab,kf,ti. 1 043
22. or/ 13-21 220 373
Combined sets:
23. 4 and 12 [high flow nasal cannula and aerosol] 67
24. 4 and 22 [high flow nasal cannula and disease transmission] 35
25. 7 and 8 [nebulisers and aerosol generating] 560
26. 7 and 22 [nebulisers and disease transmission] 354
Final 23 or 24 or 25 or 26 976

 

Cochrane Library via Wiley 200429 
High Flow Nasal Cannula
Search terms Items found
Intervention:
1. (“high flow” NEAR/3 (nasal OR oxygen OR cannula)):ti,ab,kw 1 127
2. (HFNC) :ti,ab,kw 360
3. (HFNOT) :ti,ab,kw 3
4. 1 OR 2 OR 3 1 155
5. [Nebulizers and Vaporizers] explode all trees 2 282
6. (nebulis* OR nebuliz*):ti,ab,kw 5 756
7. 5 OR 6 6 204
Outcome:
8. [Aerosols] explode all trees 2 348
9. (aerosol* OR bioaerosol*):ti,ab,kw 5 723
10. 8 OR 9 5 904
11. ((aerosol* OR bioaerosol*) NEAR/3 (generat* OR fugitive OR dispers* OR exhal* OR secondary)) :ti,ab,kw 123
12. [Disease Transmission, Infectious] explode all trees 855
13. [Cross Infection] explode all trees 1 256
14. [Infection Control] 528
15. ((disease OR virus) NEAR/3 transmission) :ti,ab,kw 1 675
16. (“infection control”) :ti,ab,kw 1 536
17. (nosocomial) :ti,ab,kw 1 619
18. (hospital NEAR/1 (acquired OR infection)) :ti,ab,kw 1 366
19. (infection NEAR/3 risk*):ti,ab,kw 4 702
20. (virus NEAR/3 survival) :ti,ab,kw 119
21. 12 OR 13 OR […] 20 10 621
Combined sets:
22. 4 AND 10 (high flow nasal cannula AND aerosol) 21
23. 4 AND 21 (high flow nasal cannula AND disease transmission) 18
24. 7 AND 11 (nebuliser AND aerosol generating) 56
25. 7 AND 21 (nebuliser AND disease transmission) 60
Final 22 OR 23 OR 24 OR 25 152

 

Embase via embase.com 200429 
High Flow Nasal Cannula
Search terms Items found
Intervention:
1. ‘high flow nasal cannula’/exp 289
2. ‘high flow oxygen therapy’/exp 51
3. ‘high flow nasal cannula oxygen therapy’/exp 44
4. (‘high flow’ NEAR/3 (nasal OR oxygen OR cannula)):ti,ab,kw 3 413
5. hfnc:ti,ab,kw 990
6. hfnot:ti,ab,kw 8
7. 1 OR 2 OR […] 6 3 530
8. ‘nebulizer’/exp 10 029
9. nebulis*:ti,ab,kw OR nebuliz*:ti,ab,kw 15 965
10. 8 OR 9 20 698
Outcome:
11. ‘aerosol’/exp 57 517
12. ‘bioaerosol’/exp 168
13. Aerosol*:ti,ab,kw 64 658
14. Bioaerosol*:ti,ab,kw 2 337
15. 11 OR 12 OR 13 OR 14 85 019
16. ((aerosol* OR bioaerosol*) NEAR/3 (generat* OR fugitive OR dispers* OR exhale* OR secondary)):ti,ab,kw 6 338
17. ‘disease transmission’/exp 252 171
18. ‘infection control’/exp 106 349
19. ‘infection risk’/exp 82 155
20. ‘hospital infection’/exp 46 187
21. ‘virus survival’/exp 1 107
22. ((disease OR virus) NEAR/2 transmission):ti,ab,kw 16 324
23. (hospital NEXT/1 (acquired OR infection)):ti,ab,kw 18 654
24. ‘infection control’:ti,ab,kw 28 742
25. (virus NEAR/2 survival):ti,ab,kw 623
26. 17 OR 19 OR […] 25 474 190
Combined sets:
27. 7 AND 15 [high flow nasal cannula AND aerosol] 119
28. 10 AND 16 [nebuliser AND aerosol generating] 702
29. 7 AND 26 [high flow nasal cannula AND disease transmission] 62
30. 10 AND 26 [nabuliser AND disease transmission] 501
Final 27 OR 28 OR 29 OR 30 1 327

 

CINAHL via ebsco.com 200429 
High Flow Nasal Cannula
Search terms Items found
Intervention:
1. MH “Nebulizers and Vaporizers” 5 400
2. TI(nebulis* OR nebuliz*) OR AB(nebulis* OR nebuliz* ) OR SU(nebulis* OR nebuliz* ) 6 601
3. 1 OR 2 6 601
4. TI((“high flow” N3 (nasal OR oxygen OR cannula)) ) OR AB((“high flow” N3 (nasal OR oxygen OR cannula)) ) OR SU((“high flow” N3 (nasal OR oxygen OR cannula)) ) 1 103
5. TI(HFNC OR HFNOT) OR AB(HFNC OR HFNOT ) OR SU(HFNC OR HFNOT ) 288
6. 4 OR 5 1 117
Outcome:
7. MH “Aerosols” 3 041
8. TI(aerosol* ) OR AB(aerosol* ) OR SU(aerosol* ) 5 311
9. TI(bioaerosol* ) OR AB(bioaerosol* ) OR SU(bioaerosol* ) 226
10. 7 OR 8 OR 9 5 400
11. TI(((aerosol* OR bioaerosol*) N3 (generat* OR fugitive OR dispers* OR exhal* OR secondary)) ) OR AB(((aerosol* OR bioaerosol*) N3 (generat* OR fugitive OR dispers* OR exhal* OR secondary))  ) OR SU(((aerosol* OR bioaerosol*) N3 (generat* OR fugitive OR dispers* OR exhal* OR secondary)) ) 401
12. MH “Disease Transmission+” 15 351
13. MH “Infection Control” 28 601
14. MH “Cross Infection” 27 982
15. TI(((disease OR virus) N2 transmission) ) OR AB(((disease OR virus) N2 transmission) ) OR SU(((disease OR virus) N2 transmission) ) 18 202
16. TI(((hospital N1 (acquired OR infection)) ) OR AB(((hospital N1 (acquired OR infection)) ) OR SU(((hospital N1 (acquired OR infection)) ) 7 120
17. TI(“infection control” ) OR AB(“infection control” ) OR SU(“infection control” ) 34 088
18. TI(virus N3 survival ) OR AB(virus N3 survival ) OR SU(virus N3 survival ) 138
19. TI(infection N2 risk ) OR AB(infection N2 risk ) OR SU(infection N2 risk ) 17 165
20. TI(nosocomial ) OR AB(nosocomial ) OR SU(nosocomial ) 7 931
21. 12 OR 13 OR […] 20 87 380
Combined sets:
22. 3 AND 11 [nebuliser AND aerosol generating] 101
23. 6 AND 10 [high flow nasal cannula AND aerosol] 33
24. 3 AND 21 [nebuliser AND disease transmission] 170
25. 6 AND 21 [high flow nasal cannula AND disease transmission] 11
Final 22 OR 23 OR 24 OR 25 301
Page published