Practical Guide for Doctors / Paramedics / Caregivers

Scrub your hands and forearms for 2–6 minutes with an antimicrobial soap. Alternatively, sanitise your hands using alcohol-based hand sanitisers with 60–70% or more alcohol content.

Nebulisation should be conducted in a separate AIIR/negative-pressure room (or at least a well-ventilated room – but one from which air cannot circulate to other parts of the facility or rooms of the house). Place a signboard stating ‘CAUTION: ‘Aerosol Generating Procedure Ongoing’ outside the room door.

HCWs should wear a face mask/N95 respirators, FFP2 or equivalent/respirator and facial protection before entering the nebulisation room. If a respirator is not available, use PPE (eye protection, face mask, face shield, gloves, shoe and head covers and gown) during nebulisation.

Ensure proper sterilisation or high-level disinfection of nebuliser accessories:

Change nebulisers between patients only after using sterilisation or high-level disinfection, or prefer single-use nebulisers, if possible.

Only essential staff, provided they are wearing the necessary PPE, should be allowed to enter the room, and visitors should be strictly prohibited.

Ideally, nebulisation should be performed in an AIIR/negative-pressure room, whenever feasible, or in a portable anteroom.

If an AIIR is not available, use a well-ventilated room – but one from which air does not circulate to other areas [part that is not connected to the central air-conditioning], thereby minimising the exposure risk for the HCWs. (e.g. single room with door closed and away from other high-risk patients).

Sit upright in a comfortable position.The nebuliser should also be placed in an upright position. When inhaling, breathe deeply and, if possible, try to hold the breath for as long as is comfortably possible. Stop the nebuliser in case you want to cough or sneeze and tap on the outside of the nebuliser medication cup occasionally to fully utilise the medicine inside it.

Using a mouthpiece prevents the aerosolised mist from escaping in the surrounding environment. Also, use of mouthpiece is associated with better improvement in lung function as compared with a face mask.

In all cases, leave the room vacant with the door closed for 30 minutes after nebulisation, after the patient has vacated the room.

Cleaning of nebuliser accessories (interface, medication cup and tubing):

Clean with water or mild detergent solution. Disinfect with 70% isopropanol or (3%) hydrogen peroxide. Rinse with tap water. Air-dry after every use.

Many disinfectants are active against enveloped viruses, such as the COVID-19 virus, including commonly used hospital disinfectants. Currently, the World Health Organization (WHO) recommends using 70% ethyl alcohol to disinfect small areas between uses, such as reusable dedicated equipment; and sodium hypochlorite at 0.5% concentration (equivalent to 5,000 ppm) for disinfecting surfaces.

Visibly dirty surfaces should first be cleaned with a detergent (commercially prepared or soap and water) and then a hospital-grade disinfectant should be applied.

The sharing of PPE kits (eye protection, face mask, faceshield, gloves, shoe and head covers, and gown) should be avoided at all costs. Using disposable equipment is strongly recommended.