Risk of Transmitting Coronavirus Disease 2019 During Nebulizer Treatment: A Systematic Review.
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2021-06
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Rationale: There is an urgent need to understand the risk of viral transmission during nebulizer treatment of patients with coronavirus disease 2019 (COVID-19). Objectives: To assess the risk of transmitting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), SARS, Middle East respiratory syndrome (MERS), and influenza with administration of drugs via nebulizer. Methods: We searched multiple electronic databases, including PubMed®, China National Knowledge Infrastructure, Wanfang, preprint databases, and clinicaltrials.gov through December 1, 2020. Any study design in any language describing the risk of viral transmission with nebulizer treatment was eligible. Data were abstracted by one investigator and verified by a second. Results: We identified 22 articles: 1 systematic review, 7 cohort/case-control studies, 7 case series, and 7 simulation-based studies. Eight individual studies involved patients with SARS, five involved MERS, and one involved SARS-CoV-2. The seven cohort/case-control studies (four high risk of bias [ROB], three unclear ROB) found mixed results (median odds ratio 3.91, range 0.08-20.67) based on very weak data among a small number of health care workers (HCWs) with variable use of personal protective equipment (PPE). Case series had multiple potential contributors to transmission. Simulation studies found evidence for droplet dispersion after saline nebulization and measureable influenza viral particles up to 1.7 m from the source after 10 minutes of nebulization with a patient simulator. Study heterogeneity prevented meta-analysis. Conclusions: Case series raise concern of transmission risk, and simulation studies demonstrate droplet dispersion with virus recovery, but specific evidence that exposure to nebulizer treatment increases transmission of coronaviruses similar to COVID-19 is inconclusive. Tradeoffs balancing HCW safety and patient appropriateness can potentially minimize risk, including choice of delivery method for inhaled medications (e.g., nebulizer vs. metered dose inhaler) and PPE (e.g., N95 vs. surgical mask).
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Goldstein, Karen M, Kamrouz Ghadimi, Harry Mystakelis, Yuanyuan Kong, Tongtong Meng, Sarah Cantrell, Megan Von Isenburg, Adelaide Gordon, et al. (2021). Risk of Transmitting Coronavirus Disease 2019 During Nebulizer Treatment: A Systematic Review. Journal of aerosol medicine and pulmonary drug delivery, 34(3). pp. 155–170. 10.1089/jamp.2020.1659 Retrieved from https://hdl.handle.net/10161/29716.
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Scholars@Duke
Karen M. Goldstein
Dr. Goldstein's research interests include women's health, cardiovascular risk reduction, evidence synthesis methodology and peer support.
Kamrouz Ghadimi
Dr. Kamrouz (Kam) Ghadimi is an experienced cardiovascular acute care specialist (cardiovascular anesthesiology and intensive care), established investigator, physician leader, and associate professor of Anesthesiology and Critical Care at Duke Health.
His clinical practice is rooted in the cardiothoracic surgical ICU and operating rooms. He has broad expertise in all topics involving perioperative cardiovascular medicine and intensive care, including the management of acutely ill patients after surgery or those receiving extracorporeal life support (ECLS/ECMO). His specific area of expertise focuses on the enhancement of blood circulation through the lungs and the reversal of bleeding with prevention of thrombosis after surgery and circulatory life support. He has published original research, invited reviews, and guidance documents in several high-impact multidisciplinary journals and networks, including JAMA, Circulation, BMJ, Journal of the American College of Cardiology, Journal of Heart and Lung Transplantation, and Journal of Thrombosis & Haemostasis. He has also published in anesthesiology specialty journals, including Anesthesia & Analgesia, Anesthesiology, Current Opinion in Anesthesiology, and the British Journal of Anaesthesia. Dr. Ghadimi has served on the Editorial Board for the Journal of Cardiothoracic and Vascular Anesthesia since 2018 and has served as a peer reviewer for more than 30 top-medical journals worldwide.
Over his career, he has developed a global multidisciplinary network of collaborators and colleagues in academic medicine, private practice, larger healthcare systems, and offices of the federal government. He has experience with grant funding from a variety of sponsors, including federal, industry, foundation, philanthropy, and institutional sources. He also holds positions on several other national and international committees aimed at improving cardiovascular health in patients undergoing surgery and post-surgical intensive care. He is a selected task force and writing committee member of the 2024 American College of Cardiology and American Heart Association Perioperative Cardiovascular Guidelines. He has devoted the majority of his career to the service of patients requiring cardiovascular perioperative and surgical intensive care.
In addition to a doctorate in Medicine, Dr. Ghadimi holds a Bachelor’s in Economics from Boston University and a Master’s in Clinical Research from Duke University School of Medicine and the National Institutes of Health. He is also an inventor with patents/patents pending, a medical consultant, a mentor, and an investor. He is a founding member and the original academic director of True Learn, an eLearning company focused on board exam preparation for multiple medical subspecialties. This resource is used by many physicians around the country. Beyond developing an educational platform that has reached several thousand physicians and physicians-in-training, Dr. Ghadimi has formally mentored 22 pre-doctorate and post-doctorate trainees, with several mentees continuing their faculty careers in academic practice. In addition, he serves as a resource for a multitude of other physicians, physicians-in-training, and allied healthcare professionals.
Currently, Dr. Ghadimi serves as Director of the Clinical Research Unit for the Department of Anesthesiology at Duke Health, leading a cohesive, high-performing management team that oversees 45 staff working with Anesthesiology faculty and faculty in other departments to operationalize more than 80 innovative research protocols annually (single- and multi-site studies) to advance the fields of perioperative medicine, intensive care, pain management, and brain and heart health. He is leading digital health and artificial intelligence implementation in research workflow to rapidly leverage capabilities for automation and efficiency with the evolving guidance of cybersecurity compliance. He has also led the expansion of the Human Biospecimen Repository within the Department of Anesthesiology, where participants from prospective studies have generously donated biofluids and tissue for the advancement of disease-specific biology and translational research. Dr. Ghadimi is currently involved in the One Duke Gen precision medicine initiative for Duke Health to catalyze high-impact translational discoveries through expansive data-driven partnerships.
Sarah Cantrell
Sarah Cantrell (she/her/hers) is the Associate Director for Research & Education at the Medical Center Library & Archives, and is responsible for developing, implementing, and evaluating the Library's research and education programs. She is also the liaison to the Graduate Medical Education programs. Sarah is currently on the steering committee of the Evidence-Based Practice for Health Sciences Librarians workshop, and co-director of the Evidence-Based Practice for the Medical Librarian course at the University of North Carolina at Chapel Hill School of Information and Library Science. Sarah served as a Co-Director of Duke's national Evidence-Based Practice (EBP) workshop for clinicians and librarians from 2019 to 2024. Before joining Duke, she worked at Walter Reed National Military Medical Center in Bethesda, MD, where she established a Clinical Librarian Program and joined inpatient care teams for teaching rounds, providing real-time evidence-based decision support and teaching at the point of care. Prior to WRNMMC, she was the Education Services Coordinator and Instruction Librarian at Georgetown University Medical Center's Dahlgren Memorial Library in Washington, DC.
- MLIS, Library & Information Studies, University of Wisconsin Madison
- BA, English Literature, University of Wisconsin Madison
Megan Von Isenburg
Megan is Associate Dean for Library Services & Archives at the School of Medicine. Megan is responsible for planning and implementing high quality information services and resources to support the missions of Duke Health. She provides leadership for the Duke University Medical Center Library, which serves as a resource library for the state of North Carolina and the Mid-Atlantic region and is known for its innovations in health sciences librarianship and expertise in evidence-based practice. Von Isenburg also oversees the retention and preservation of institutional records through Medical Center Archives services. In addition to providing access to administrative records, the Archives capture the history of Duke Medicine through its record retention services.
Graduate Certificate in e-Learning, North Carolina State University (2011)
MSLS Library Science, University of North Carolina at Chapel Hill (2004)
BA, American Studies, University of North Carolina at Chapel Hill (1997)
Jennifer M. Gierisch
Jennifer Gierisch, PhD, is behavioral scientist and health services researcher. She is an Associate Professor in the Department of Population Heath Sciences and the Department of Medicine at Duke University. She is a core investigator with the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) where she serves as the leader of the Partnered Research Methods Core (PRESTO) and Director of the VA OAA Health Services Research Postdoctoral Fellowship. Dr. Gierisch also is the Co-Director of the Evidence Synthesis Program (VA ESP) at the Durham Veteran Affairs Health Care System. She also served as a faculty director of the Duke Clinical Translational Science Institute's Community Engaged Research Initiative (CeRi) for five years
Dr. Gierisch’s research focuses on three overarching areas: 1) behavioral research on the psychosocial factors that influence appropriate uptake and maintenance of complex health behaviors (eg., weight management, smoking cessation, cancer screening); 2) evidence synthesis on key health and healthcare topics to enhance uptake of evidence-based interventions to improve patient and health system outcomes; and 3) participatory and community engaged research approaches.
Area of expertise: health behavior, community-engaged research, evidence synthesis, intervention development, qualitative research
John Wiley Williams
John Williams, MD, MHS, is a Professor of Medicine at Duke University Medical Center and a past recipient of VA Health Services Career Development and a Robert Wood Johnson Foundation Generalist Faculty Scholar Awards. He received his bachelor and MD degrees from the University of North Carolina. Dr. Williams completed residency training at the University of Iowa and a research fellowship at Duke University. He is a primary care internist who is trained in epidemiology, biostatistics, and literature synthesis. Dr. Williams’ topical interests include depression, mental health services, dementia and implementation of best practices. He is a medical editor for the Patient Centered Outcomes Research Institute and the Evidence-base Practice Program. Dr. Williams is Senior Science Advisor to the Durham VA Evidence Synthesis Program and has led numerous systematic reviews, many focusing on mental health services. Dr. Williams is board certified in Internal Medicine and active in clinical practice and resident physician education at the Durham VAMC.
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