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Back to Journal »International Journal of Chronic Obstructive Pulmonary Disease» Volume 16

Author Ari A, Blain K, Soubra S, Hanania NA

Published on September 28, 2021, the 2021 volume: 16 pages 2687-2695

DOI https://doi.org/10.2147/COPD.S332021

Single anonymous peer review

Editor who approved for publication: Dr. Richard Russell

Video summary provided by Arzu Ari.

Arzu Ari,1 Karen Blain,2 Said Soubra,1 Nicola A Hanania3 1 Department of Respiratory Nursing, Texas State University, Round Rock, Texas; 2Department of Respiratory Therapy, University of North Carolina, Wilmington, Wilmington, North Carolina, USA; 3Airways Clinical Research Center, Baylor College of Medicine, Houston, Texas, USA Corresponding author: Arzu Ari Email [email protected] Abstract: COVID-19 has affected hundreds of people worldwide Thousands of patients, nursing staff and clinicians. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is spread through droplets and close contact between people. Due to the potential aerosolization of virus particles, people are paying more and more attention to aerosol administration. So far, few people have paid attention to aerosol administration to COVID-19 patients receiving treatment at home to minimize their utilization in the hospital. As most hospitals face multiple admission pressures during the COVID-19 pandemic and limited medical resources, treating COPD patients at home has become critical to minimizing hospital utilization. However, there is still a lack of guidance on how to safely and effectively provide aerosolized drugs to patient groups receiving treatment at home. In this article, we provide some strategies and basic principles of equipment and interface selection, delivery technology, and infection control for COPD patients receiving treatment at home during COVID-19 and beyond. Keywords: Coronavirus, COVID-19, SARS-CoV-2, aerosol, nebulizer, inhaler, home care, infection control

COVID-19 is caused by SARS-CoV-2, a new type of coronavirus that affects millions of people around the world because this respiratory disease spreads from person to person through droplets and close contact. 1 It is well known that respiratory viruses can exacerbate COPD and worsen patients' symptoms. 2 Although nebulized drugs are often used to treat COPD patients, virus particles may be nebulized, especially in hospital settings. During the COVID-19 pandemic, hospitals were under pressure due to the admission of a large number of patients, and there was a lot of discussion on the management of critically ill patients with limited medical resources, but little attention was paid to the management strategies and guidance of clinicians and patients with chronic lung diseases. Illnesses treated at home. Evidence-based guidelines on how to safely and effectively provide aerosolized drugs to patient groups receiving treatment at home are still lacking. The purpose of this review is to discuss some strategies and provide the underlying rationale for equipment selection, interface selection, delivery technology, and infection control for managing COPD patients at home in COVID-19 and beyond.

Previous research reports stated that severe acute respiratory syndrome (SARS) coronavirus and Middle East respiratory syndrome coronavirus (MERS-CoV) have similar clinical features and results to COVID-19.3. For MERS-CoV in asthma, 4 patients with chronic lung disease are also considered to be at increased risk of contracting COVID-19. However, this hypothesis has not been confirmed in several reports, and there is conflicting evidence regarding the risks and potential consequences of COVID-19 in this population. 5 Halpin et al. proved that the prevalence of asthma and COPD in patients diagnosed with COVID-19.6 is lower. The authors speculate that this may be due to the treatment of chronic lung diseases, such as inhaled corticosteroids, which can not only reduce infections Risks can also reduce the development of severe symptoms of COVID-19. In fact, the Global Asthma Initiative (GINA) and Global Obstructive Lung Disease Initiative (GOLD) strategies continue to recommend the use of prescription inhaled medications in asthma and COPD to prevent the symptoms and severity of the disease from worsening. 7,8 According to previous studies, 40–60% of COPD exacerbations are caused by viral infections. 2 Since COPD is considered to be a potential disease that may be related to the severity of the disease, it is important to recommend that COPD patients continue to take inhaled drugs at home to control the disease. 9 However, the outcome of aerosol treatment of patients depends on the characteristics of the patient and the choice for use. Compatibility of the characteristics of the therapeutic aerosol device.

There are several factors that influence the choice of equipment for inhaled medication. What matters are patient characteristics, such as age, degree of obstruction, physical and cognitive abilities, and patient preferences. In addition, the characteristics of the aerosol device, such as availability, cost, reimbursement, and ease of use, are also critical. 10-13 Aging reduces the peak inspiratory flow rate (PIFR) and increases the risk of invalid inhalation in the inhaler. 14,15 In addition, patients’ errors in using inhalers increase with increasing airway obstruction. 14,16 Therefore, regular inhalers may not be suitable for elderly patients with severe COPD. Many host factors increase the risk of serious errors during inhaler aerosol administration. These factors include impaired hand mobility, decreased respiratory muscle strength, hearing loss, visual impairment, physical loss of hand and finger muscles, cognitive dysfunction, and neuromuscular diseases. Insufficient hand strength may make it impossible to use a pressurized metered-dose inhaler (pMDI). In addition, dry powder inhalers (DPI) may not be suitable for this patient population because of impaired hand dexterity and low PIFR. It will be difficult for a patient to put a unit-dose drug into the reservoir of the device and use the unit-dose DPI effectively. Although visual impairments may affect the correct loading of the inhaler and the ability to view the dose counter, patients with hearing impairments may not be able to understand the "click" that indicates preparation for inhalation through the DPI. Decreased respiratory muscle strength may also reduce the patient's ability to produce the minimum flow and volume required for proper operation of the inhaler. 17 Therefore, patients should be regularly assessed for their potential to understand how and when to use aerosol devices to determine their cognitive abilities. Failed cognitive tests indicate that conventional inhalers may not be suitable for patients. 17 Patient preference is related to good inhalation technology, which can improve patient compliance with prescribed treatment. 18-20 Patients prefer the use of small, portable and easy-to-use aerosol devices. If the aerosol device has a short treatment time, requires less cleaning/maintenance, and is the least out-of-pocket cost for the patient, it is considered convenient. Therefore, patient preference and equipment convenience are other important factors that need to be considered when selecting equipment. However, only 35% to 37% of healthcare providers believe that the type of aerosol device is very important when prescribing inhaled medications for newly diagnosed patients with stable COPD and patients with acute exacerbations. 21 In addition, healthcare providers prioritize inhaled medications over device therapy when choosing inhaled medications, and at the same time have limited attention to the correct use of aerosol devices. twenty one

Although it is important to avoid unnecessary aerosol treatments for COPD patients who test positive for infectious diseases such as COVID-19, clinicians need to choose the right equipment, the right interface, and the right drugs for the right patients who need treatment . In COVID-19 and beyond, use nebulized medication for treatment. Therefore, clinicians should be trained in device selection, interface selection, delivery technology, device preparation, cleaning, and maintenance (Table 1). For example, inhalers should take precedence over nebulizers to minimize nebulization, unless the patient is unable to perform the specific breathing techniques required to effectively use prescription inhalers. 22,23 The use of pMDI for effective aerosol therapy requires the best delivery technology. By achieving good hand-breath coordination, start the pMDI at the beginning of the inhalation, breathe slowly, and hold the breath at the end of the inhalation. 10-12,24,25 Since patients are concerned about the effectiveness of the drug but not the correct inhalation technique, 21,26 92% of COPD patients and asthma patients have at least one error in the inhalation technique. 27 For patients with poor technique, the use of valved holding chambers should be encouraged when using pMDI. If the patient is still unable to take the required steps for the best technique using pMDI, then DPI should be considered to deliver the DPI to a patient who can achieve sufficient inspiratory flow rates for the specific device. 9,22,23 Since each DPI requires a different inspiratory flow rate for optimal aerosol administration,28 assessment of patient abilities and performance, patient education and follow-up are essential to achieve optimal disease management of COPD. 24 Table 1 Options and reasons for aerosol administration to COPD patients who were diagnosed with COVID-19 and received treatment at home

Table 1 Options and reasons for aerosol administration to COPD patients diagnosed with COVID-19 and receiving treatment at home

Unfortunately, there is a shortage of inhalers during the COVID-19 pandemic in the United States. 29,30 When the pharmaceutical preparation cannot be used as an inhaler or the patient cannot use the inhaler to perform a specific breathing technique, a nebulizer can be used to deliver aerosolized drugs. 9,22,23 The different types of nebulizers available include: (1 ) Jet atomizer, and (2) Mesh atomizer. 31 Although jet nebulizers are cheaper than mesh nebulizers, two-thirds of the aerosols produced by jet nebulizers may put other family members at risk of infection if the equipment is contaminated31-34. In this case, the use of breath-driven jet nebulizers may be a good choice because they only produce aerosols when inhaling, while traditional jet nebulizers continuously produce aerosols throughout the breathing cycle. 35 Therefore, there are fewer breath-driven nebulizers that release exhaled aerosols into the environment than traditional nebulizers. Another option is to use a mesh nebulizer for aerosol treatment in the COVID-19 era. Since the mesh nebulizer separates the drug from the patient interface through the mesh, the risk of equipment contamination in the mesh nebulizer is lower than that of the traditional jet nebulizer. In addition, the mesh nebulizer operates using a power source instead of an external airflow, which helps to diffuse the bioaerosol produced by the patient into the atmosphere. twenty three

For COPD patients receiving treatment at home in the COVID-19 era, the choice of interface is as important as the choice of equipment. The correct interface is the one that the patient can tolerate and the preferred interface. It is a reliable interface during aerosol treatment. Therefore, clinicians should consider every interface that can be combined with the aerosol device selected for patient treatment. For example, pMDI is used with gaskets or valved holding chambers (VHC). Although spacers and VHC are designed to improve the delivery efficiency of pMDI, their designs are different. The VHC has a one-way valve that contains aerosols until the patient inhales, while the gasket is a simple tube without a valve and requires some hand-breath coordination. In addition, exhaling in the pad after starting pMDI wastes most of the dose to the environment. Therefore, pMDI should be used in combination with VHC to reduce oropharyngeal deposition and the need for hand-respiratory coordination during aerosol treatment. Driving the gasket or VHC multiple times will reduce the delivery of drugs to COPD patients. 36,37 In addition, clinicians should be aware of the electrostatic charge of the gasket and VHC, which can reduce the patient's inhaled dose. Although an alternative method is to clean the pads with detergent to eliminate static charges, 38-42 another option is to use non-static pads for aerosol treatments where possible. 43

When a nebulizer is used to administer aerosols to COVID-19 patients, the mouthpiece is more popular than a face mask because it does not force the aerosol away from the interface during exhalation and breath-holding. 22,23,44 Therefore, the mouthpiece emits a lower concentration of aerosols than a mask, and installing a filter on the mouthpiece's exhalation port can reduce the diffusion of exhaled bioaerosols to the environment. 45

Several steps are required to deliver an aerosol with an inhaler. For example, shaking, priming, hand-breath coordination, and breath-holding are essential for the effective use of pMDI during aerosol therapy. 46 While shaking and starting the pMDI before treatment can ensure uniform mixing of the drug and proper filling of the metering chamber before starting, it is also important to coordinate the starting of the pMDI with inhalation, slow breathing, and breath holding after inhalation. Common errors of pMDI include insufficient shaking/priming, failure to coordinate pMDI actuation and inhalation, actuation of pMDI during expiration, rapid inhalation after actuation, multiple firing of pMDI during a single inhalation, actuation of pMDI into the mouth But inhalation through the nose, and insufficient or no breath-holding after inhalation. 36,46–50

Although DPI eliminates some of the problems associated with pMDI delivery technology, they also have their own challenges, such as using DPI in the wrong direction during device preparation or treatment, failing to pierce a blister pack or capsule before inhalation, shaking the device, breathing Insufficient air DPI or inspiratory flow rate. Each DPI has a specific inhalation flow rate requirement in order to draw the medicine from the inhaler and break the powder into small particles. Adequate inspiratory flow rate results in better decomposition and greater lung deposition and DPI. However, elderly patients with COPD may not have the physical capacity to produce sufficient inspiratory flow required for DPI. Clinicians can determine the most suitable inhaler for the patient by using a hand-held inhalation flow meter, such as In-Check-Dial (Clement Clark International Limited, UK) that simulates the resistance of ordinary inhalers. 24,51,52 This hand-held inhalation flow meter can be used for the selection of inhalers and the education of patients on the correct use of inhalers. 51-55 In addition, previous studies have shown that the patient's exhalation or humidity in the surrounding environment can cause powder to clump and reduce the efficiency of DPI delivery. 18 ,46

The delivery technology of the atomizer is very simple. Unlike pMDI and DPI, it does not require any specific breathing technique, and only normal tidal breathing is sufficient to effectively deliver aerosol during nebulizer treatment.

The spread of COVID-19 is through droplets produced as bio-aerosols, which remain viable and infectious for several hours. When the larger aerosol particles fall to the ground, the smaller particles stay in the air and travel with the airflow. In addition, it is difficult to distinguish bioaerosols from medical aerosols. Bioaerosols are produced by patients when they talk, cough, sneeze or sing. If a patient is diagnosed with COVID-19, the bioaerosol he/she exhales may contain pathogens and play an important role in the spread of coronavirus. On the other hand, medical aerosols are produced by aerosol devices used during treatment. In addition, medical aerosols that are not inhaled by the patient but enter the atmosphere are defined as fugitive emissions. Although aerosol therapy produces fugitive emissions, they are medical aerosols produced by aerosol devices, not bioaerosols produced by patients. 9,22,23 50% of the medical aerosols produced during aerosol therapy are fugitive emissions with particle sizes between 0.860 and 1.437 µm. 45,56–59 The amount and characteristics of fugitive emissions are affected by many factors The influence of the flow rate, the type of aerosol device and interface used during treatment. 58,60,61 Temperature, air turbulence and airflow rate, as well as the size and layout of the room, affect the diffusion and attenuation of fugitive emissions. A retrospective study of a summary analysis of the risks of various aerosol-producing procedures showed that compared with nebulizers, the risk of infection during intubation and non-invasive manual ventilation of medical staff is much higher. 62 A filter can be connected to the outlet of the nebulizer to capture exhaled aerosol droplets during aerosol therapy. 45,63,64 However, it must be noted that due to the lack of clinical studies in this research area, the effectiveness of these filters in preventing the spread of coronavirus is not yet clear. twenty two

Since nebulizer contamination plays a vital role in the spread of the virus and the risk of infection, in this global pandemic, it is essential to clean the nebulizer after each treatment and follow the infection control procedures during the aerosol treatment. important. Although the mesh nebulizer should be cleaned according to the manufacturer's guidelines, the jet nebulizer should be rinsed, air-dried, and/or disinfected after each treatment. 65-67 In addition, it must be borne in mind that the virus may be present in the body in the form of droplets. If a contaminated nebulizer is used for aerosol drug delivery to COVID-19 patients, the air in the air. Therefore, aerosol treatment should be performed on outdoor terraces, porches, or garages where air is not ventilated to minimize contact with uninfected family members. 9 The air exhaled in the room should be replaced with fresh air from outside. Frequent ventilation and cross ventilation are as effective as opening windows. The air purifier can reduce the concentration of indoor aerosol particles, and has the same effect as the clean air outside. Although air purifiers usually change air three to six times per hour, during a global pandemic, higher exchange rates will reduce existing particle concentrations more quickly. If the clean air delivery rate is 750 cubic meters/hour, the risk of infection/hour spent in a room with an infected person can be reduced to 10%. 68 Air purifiers should be placed where they can freely suck the room. 69 Therefore, they should not be placed behind furniture or under tables. Air purifiers have many shortcomings such as fan noise, cost, and power consumption, which may reduce their acceptance in daily life. 70 In addition, regular replacement of air purifier filters is a necessary condition for maintaining efficiency. In the process of using air purifiers, other protective measures such as wearing masks, maintaining social distancing, and ventilation are still essential.

Patients should also be isolated in a room, not only to avoid shared spaces, but also to avoid the use of personal household items such as tableware, towels or bedding as much as possible. 71 If they must use shared spaces, they should keep a distance of at least 1 m from others. Others, 9, 71, 72 wear masks when they are close to their families and change their masks every day. 71 Keeping distance from other family members will help to dilute the exhaled bioaerosol containing the virus; therefore, the probability of disease spreading to other family members will be reduced. The use of a mask will reduce the concentration of exhaled bioaerosols in the room by filtering the exhaled bioaerosols when breathing, talking, coughing or sneezing. It is also important to note that using a face mask without wearing a face mask is ineffective in controlling infection, because the exhaled bioaerosol containing pathogens is not filtered when flowing around the mask. Generally, face masks are used to prevent droplet infections through the mucous membranes of the eyes. Similarly, Plexiglas barriers designed for home care cannot effectively prevent the spread of infected bioaerosols indoors because they can prevent large particles from splashing and splashing. When coughing and sneezing, patients should also cover their mouth and nose with a tissue that needs to be thrown away immediately. 71,72 Cleaning frequently touched surfaces in a separate room, washing hands with soap and water for 20 seconds, and using hand sanitizer with an alcohol content of at least 60% is important to prevent the spread of infection. 71 Otherwise, non-compliance with infection control procedures and exposure to the virus will be a problem for uninfected family members. It is also important to provide training to caregivers to reduce the risk of exposure to the virus while caring for COVID-19 patients. The World Health Organization has developed excellent home care and infection control guidelines for COVID-19.71 patients

Because it is a new and highly spread virus, many countries have implemented infection control measures to isolate or isolate individuals infected or exposed to the coronavirus. In addition, policymakers have also formulated regulations on social distancing and blockades to protect the most vulnerable groups. Patients and their caregivers should follow the doctor’s advice regarding their treatment and home isolation. In order to improve the health and well-being of COPD patients at home, telemedicine can be used for disease management, patient monitoring and evaluation, and training of patients and caregivers for optimal aerosol administration and infection control. Novel Coronavirus Pneumonia (COVID-19): New Coronary Pneumonia (COVID-19): COVID-19. Although telemedicine has faced some obstacles in the past, such as cost, regulation, technology and equipment challenges, technological progress and recent medical reforms have reduced these obstacles. Therefore, in the COVID-19 era, the penetration rate of telemedicine is increasing. Although some studies on telemedicine showed improvements in the prognosis, satisfaction, hospitalization rate, anxiety and depression of COPD patients, 73-83 others reported no significant improvement 82-86. The conflicting results of previous studies may be due to patients Assessment of the high degree of variability, severity of disease, type of technology, and service lines used in these studies. According to previous research, telemedicine can reduce the number of visits to primary care and emergency departments, 73-76,81,87,88 provide better disease management 73,76,78,79,83,87 strengthen patient and clinician Relationship, 77, 85, 89, 90 and increase patient empowerment and participation in COPD. 73,75,76,89,90 In addition, it helps to increase access to care during home isolation and lockdown periods and in rural areas where care may not be available. Previous studies have shown that additional services such as video conferencing and telephone support have been added to traditional COPD management through telemedicine, thereby improving COPD and reducing hospitalization rates related to deterioration. 86,88 In addition, obtaining a respiratory therapist or nurse at the same time is a logical approach that should improve patient education and outcomes. It may increase the workload of clinicians and the cost of providing services to patients with COPD. 77-79,85,90,91 Other obstacles to telemedicine include lack of service standardization, 77, 78,84,87,89 patients are uncomfortable with technology, 79,80,87 patient autonomy is reduced, 74,85,89 consumption At the time, 77,87 considered the lack of practicality, 90 and the resistance of patients/caregivers to the use of telemedicine. 77 Despite many obstacles, telemedicine is still a viable option for patients with COPD, as current medical resources are limited compared with the increasing demand during the COVID-19 pandemic. Therefore, it is necessary to develop alternative strategies to improve the clinical pathway of treating COPD patients at home in the COVID-19 era.

Given the unknowns of this global pandemic, actions must be taken to ensure the resilience and well-being of COPD patients in COVID-19 and beyond. Patient education and improved access to healthcare are the most urgent needs of COPD patients. Therefore, the use of telemedicine in this patient population is crucial, while at the same time formulating and implementing innovative strategies to achieve the success of clinical standards, and establishing self-management practices in the provision of aerosol drugs to COPD patients treated at home. Through recommended treatment strategies in terms of equipment selection, interface selection, delivery technology, and infection control, clinicians can provide safe and effective treatment for COPD patients treated at home for COVID-19 and beyond.

No funds were obtained when preparing this manuscript.

Dr. Ari disclosed her relationship with Aerogen Ltd, Boehringer Ingelheim and Philips Healthcare. Dr. Hanania was honored for serving as a consultant or advisory board for GlaxoSmithKline, Sanofi, Regeneron, Genentech, Novartis, Boehringer Ingelheim, AstraZeneca, Teva, Amgen and Mylan Pharmaceuticals. His institution has received research funding from GlaxoSmithKline, Sanofi, Genentech, Gossamer Bio, Boehringer Ingelheim, Novartis and AstraZeneca. The authors report no other conflicts of interest in this work.

1. Interim US guidelines for risk assessment and public health management for medical staff who may be exposed to patients with coronavirus disease (COVID-19) in the medical environment. Centers for Disease Control and Prevention; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html. Visited on September 14, 2021.

2. Johnston SL. Overview of airway diseases caused by viruses. Proc Am Thorac Soc. 2005;2(2):150–156. doi:10.1513/pats.200502-018AW

3. Yin Y, Wunderink RG. MERS, SARS and other coronaviruses are the causes of pneumonia. Respirology. 2018;23(2):130–137. doi:10.1111/resp.13196

4. Kerkhove V, Alaswad S, Assiri A, etc. The spread of MERS-CoV infection in a closed environment. Emergency infection. 2015; 25: 1802-1809.

5. Assaf SM, Tarasevych SP, Diamant Z, Hanania NA. Asthma and severe acute respiratory syndrome coronavirus 2019: current evidence and knowledge gaps. Curr Opin Pulm Med. 2021;27(1):45–53. doi:10.1097/MCP.0000000000000744

6. Halpin DMG, Faner R, Sibila O, Badia JR, Agusti A. Does chronic respiratory disease or its treatment affect the risk of SARS-CoV-2 infection? Lancet respiratory medicine. 2020; 8(5): 436–438. doi:10.1016/S2213-2600(20)30167-3

7. Recommendations for inhaled asthma control drugs. Global Asthma Initiative; 2020. Available from: https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/. Visited on September 14, 2021.

8. The Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD). 2020 Global Strategy Report on the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease; 2020. Available from: http://www.goldcopd.org. Visited on September 14, 2021.

9. Ari A. Use nebulized drugs to treat COVID-19 at home. Lancet respiratory medicine. 2020; 8(8): 754–756. doi:10.1016/S2213-2600(20)30270-8

10. Ari A, Restrepo RD. Selection of aerosol delivery devices for patients with spontaneous breathing: 2012. Respiratory care. 2012; 57(4): 613–626. doi:10.4187/respcare.01756

11. Ari A, Fink J. A guide to aerosol devices for infants, children, and adults: which one to choose, why and how to achieve effective aerosol therapy? Expert Rev Respir Med. 2011; 5(4): 561–572. doi:10.1586/ers.11.49

12. Ali A, Fink JB. Differential medical aerosol device and interface selection for patients during spontaneous, conventional mechanical and non-invasive ventilation. J Aerosol Med Pulm Drug Deliv. 2016;29(2):95–106. doi:10.1089/jamp.2015.1266

13. DePietro M, Gilbert I, Millette LA, Riebe M. Selection of inhalation devices for chronic obstructive pulmonary disease management. Postgraduate medicine. 2018;130(1):83-97. doi:10.1080/00325481.2018.1399042

14. Wieshammer S, Dreyhaupt J. Dry powder inhalers: What factors determine the frequency of handling errors? breathe. 2008;75(1):18-25. doi:10.1159/000109374

15. Jarvis S, Ind PW, Shiner RJ. Inhalation therapy in elderly patients with COPD; when is the reassessment? Aging with age. 2007;36(2):213-218. doi:10.1093/ageing/afl174

16. Fromer L, Goodwin E, Walsh J. Customize inhalation therapy to meet the needs of COPD patients. Postgraduate medicine. 2010;122(2):83-93. doi:10.3810/pgm.2010.03.2125

17. Lavorini F, Mannini C, Chellini E, Fontana GA. Optimizing inhaled drug therapy for elderly patients with chronic obstructive pulmonary disease: the importance of delivery devices. Drug aging. 2016;33(7):461–473. doi:10.1007/s40266-016-0377-y

18. Fink JB, Rubin BK. Inhaler use issues: Call for improved clinician and patient education. Respiratory care. 2005;50:1360-1374.

19. Fink JB. Inhalers in asthma management: is demonstration the key to compliance? Respiratory care. 2005;50:598-600.

20. Lewis RM, Fink JB. Promote compliance with inhalation therapy: build partnerships through patient education. Respiratory care clinical N morning. 2001;7(2):277–301, vi. doi: 10.1016/S1078-5337(05)70034-4

21. Hanania NA, Braman S, Adams SG, etc. The role of inhaled drug delivery devices in COPD: the perspectives of patients and healthcare providers. Chronic obstructive pulmonary disease. 2018;5(2):111–123. doi:10.15326/jcopdf.5.2.2017.0168

22. Ari A. Practical strategies for the safe and effective delivery of nebulized drugs to COVID-19 patients. Respiratory medicine. 2020;167:105987. doi:10.1016/j.rmed.2020.105987

23. Ari A. Promoting the safe and effective use of aerosol devices in COVID-19: risks and recommendations for virus transmission. Expert opinion on drug delivery. 2020;17(11):1509-1513. doi:10.1080/17425247.2020.1811225

24. Ari A. Patient education and compliance with aerosol therapy. Respiratory care. 2015; 60(6): 941–955. doi:10.4187/respcare.03854

25. Ari A, Fink J. Aerosol therapy for children: challenges and solutions. Expert Rev Respir Med. 2013; 7(6): 665–672. doi:10.1586/17476348.2013.847369

26. Dhand R, Mahler DA, Carlin BW, etc. The results of a patient survey on COPD knowledge, treatment experience, and practice of inhalation devices. Respiratory care. 2018;63(7):833–839. doi:10.4187/respcare.05715

27. Luczak-Wozniak K, Dabrowska M, Domagala I, etc. Improper handling of pMDI and DPI inhalers in asthma and COPD-repetitive and non-repetitive errors. Pulm Pharmacol Ther. 2018;51:65-72. doi:10.1016/j.pupt.2018.06.002

28. Riley J, Krüger P. Optimizing inhaler technology for chronic obstructive pulmonary disease: a complex problem. Nurse Br J. 2017;26(7):391–397. doi:10.12968/bjon.2017.26.7.391

29. Elbeddini A, Yeats A. During the COVID-19 drug shortage: Proposed plan for reprocessing and reuse of albuterol pressurized metered-dose inhaler (pMDI) for shared use. The point of view of medication. 2020; 36:1-3.

30. Press VG, Gershon AS, Sciurba FC, Blagev DP. Concerns about collateral damage associated with coronavirus disease in COPD patients. Chest. 2020;158(3):866–868. doi:10.1016/j.chest.2020.05.549

31. Ari A. Jet, mesh and ultrasonic nebulizers: evaluation of nebulizers for better clinical practice. Eurasian J Pulmonol. 2014; 16:1-7.

32. Law JL. The design principle of the liquid atomization device currently in use. Respiratory care. 2002;47:1257-1275.

33. Ari A. The effect of nebulizer type, delivery interface and flow rate on the delivery of aerosol drugs to spontaneous breathing pediatrics and infant lung models. Pediatric pulmonary heart disease. 2019;54(11):1735-1741. doi:10.1002/ppul.24449

34. Ari A, de Andrade AD, Sheard M, AlHamad B, Fink JB. Comparison of the performance of jet and mesh nebulizers using different interfaces in simulated spontaneous breathing in adults and children. J Aerosol Med Pulm Drug Deliv. 2015;28(4):281–289. doi:10.1089/jamp.2014.1149

35. O'Toole C, McGrath J, Bennett G, Joyce M, MacLoughlin R, Byrne M. Fugitive emissions from breath-driven jet nebulizers and vibrating mesh nebulizers for pediatric patients. In: ISES-ISIAQ 2019; 2019; Kaunas, Lithuania.

36. Mitchell JP, Nagel MW. Valved holding chamber (VHC) for pressurized metered-dose inhalers (pMDI): an examination of the reasons for inconsistent drug delivery. Prim Care Respir J. 2007;16(4):207-214. doi:10.3132/pcrj.2007.00034

37. Wildhaber JH, Devadason SG, Eber E, etc. The effect of static charge, flow, delay and multiple actuation on the in vitro delivery of salbutamol in infants with different small-volume spacers. Chest. 1996;51(10):985-988. doi:10.1136/thx.51.10.985

38. Wildhaber JH, Janssens HM, Pierart F, Dore ND, Devadason SG, Lesouef PN. A high percentage of detergent-treated pads are delivered in the lungs of children. Pediatric pulmonary heart disease. 2000;29(5):389–393. doi:10.1002/(SICI)1099-0496(200005)29:5<389::AID-PPUL8>3.0.CO;2-3

39. Wildhaber J, Devadason S, Hayden M, etc. The static charge on the plastic gasket device will affect the release of salbutamol. Eur Respir J. 1996;9(9):1943-1946. doi:10.1183/09031936.96.09091943

40. Pierart F, Wildhaber J, Vrancken I, Devadason SG, Le Souef PN. Washing partitions in household detergents can reduce static charges and greatly improve delivery effects. Eur Respir J. 1999;13(3):673-678. doi:10.1183/09031936.99.13367399

41. Dompeling E, Oudesluys-Murphy AM, Janssens HM, etc. A randomized controlled study of the clinical efficacy of interval therapy in the treatment of asthma. Arch Dis kid. 2001;84(2):178-182. doi:10.1136/adc.84.2.178

42. Anhoj J, Bisgaard H, Lipworth BJ. The effect of electrostatic charge in plastic gaskets on the pulmonary delivery of HFA-salbutamol in children. Br J Clinical Pharmacology. 1999;47(3):333-336. doi:10.1046/j.1365-2125.1999.00893.x

43. Bisgaard H, Anhoj J, Klug B, Berg E. A non-static spacer for aerosol delivery. Arch Dis kid. 1995;73(3):226-230. doi:10.1136/adc.73.3.226

44. Ari A. Drug Delivery Interface: A method to optimize the inhalation therapy of spontaneously breathing children. World J Clinical Pediatrics. 2016;5(3):281–287. doi:10.5409/wjcp.v5.i3.281

45. McGrath J, O'Toole C, Joyce GB, Joyce M, Byrne MA, MacLoughlin R. Investigation of dispersible aerosols released into the environment during high flow treatment. pharmaceutics. 2019;11(6):254. doi:10.3390/pharmaceutics11060254

46. ​​Ari A. Optimize inhalation therapy for patients with spontaneous breathing. Clinical medicine. 2014;21(1):34-41. doi:10.1097/CPM.0000000000000019

47. Rubin BK. Air and Soul: The Science and Application of Aerosol Therapy. Respiratory care. 2010; 55: 911-921.

48. Law JL. Philip Kitrech Memorial Lecture in 2004. Inhaled drugs: advantages and problems. Respiratory care. 2005;50:367-382.

49. Law JL. The practical problems of COPD aerosol treatment. Respiratory care. 2006; 51: 158-172.

50. McFadden ER Jr. Improper patient technology for metered-dose inhalers: clinical consequences and misuse solutions. J Journal of Allergy Clinical Immunology. 1995;96(2):278-283. doi:10.1016/S0091-6749(95)70206-7

51. Lavorini F, Levy ML, Corrigan C, Crompton G. ADMIT series-problems in inhalation therapy. 6) Training tool for inhalation device. Prim Care Respir J. 2010;19(4):335-341. doi:10.4104/pcrj.2010.00065

52. Chrystyn H. Is the inhalation rate important for dry powder inhalers? Use check dial to determine these rates. Respiratory medicine. 2003;97(2):181-187. doi:10.1053/rmed.2003.1351

53. Fiato KL, Iwamoto GK, Harkins MS, Morelos J. Use the check dial device for adult asthmatics to monitor flow rate and retention of inhalation technique. J Asthma. 2007;44(3):209-212. doi:10.1080/02770900701209798

54. Amirav I, Newhouse MT, Mansour Y. Use check dial device to measure peak inspiratory flow to simulate low-resistance (Diskus) and high-resistance (Turbohaler) dry powder inhalers for children with asthma. Pediatric pulmonary heart disease. 2005;39(5):447–451. doi:10.1002/ppul.20180

55. van der Palen J. The peak inspiratory flow through the disk and turbo inhaler, measured by the peak inspiratory flow meter (In-Check DIAL). Respiratory medicine. 2003;97(3):285-289. doi:10.1053/rmed.2003.1289

56. Saeed H, Mohsen M, Fink J, etc. The influence of filling volume, humidification and thermal effects on aerosol transport and escape emissions during non-invasive ventilation. J Drug Deliv Sci Technol. 2017; 39: 372-378. doi:10.1016/j.jddst.2017.04.026

57. Nazaroff W. Indoor bioaerosol dynamics. Indoor air. 2016;26(1):61–78. doi:10.1111/ina.12174

58. Long C, Suh H, Catalano P, Koutrakis P. Use time- and size-resolved particle data to quantify indoor penetration and deposition behavior. Environmental science and technology. 2001;35(10):2089-2099. doi:10.1021/es001477d

59. McGrath J, Byrne M, Ashmore M, Terry A, Dimitroulopoulou C. Development of a probabilistic multi-region and multi-source calculation model and its application demonstration in predicting indoor PM concentration. The total scientific environment. 2014; 490: 798-806. doi:10.1016/j.scitotenv.2014.05.081

60. McGrath J, Byrne M, Ashmore M, Terry A, Dimitroulopoulou C. Simulation study of PM2.5 concentration changes caused by changes in airflow between regions caused by the opening pattern of the inner door. Atmospheric Environment. 2014;87:183-188. doi:10.1016/j.atmosenv.2014.01.050

61. Ciuzas D, Prasauskas T, Krugly E, etc. Temporal variation characteristics of indoor aerosols for real-time management of indoor air quality. Atmospheric Environment. 2015;118:107-117. doi:10.1016/j.atmosenv.2015.07.044

62. Tran K, Cimon K, Severn M, Pessoa-Silva C, Conly J, Semple MG. The risk of aerosol generation procedures and the spread of acute respiratory infections to health care workers: a systematic review. Public Science Library One. 2012; 7(4): e35797. doi:10.1371/journal.pone.0035797

63. Wittgen BP, Kunst PW, Perkins WR, Lee JK, Postmus PE. Evaluation of systems that capture stray aerosols during inhalation of nebulized liposomal cisplatin. J Aerosol Science. 2006;19(3):385-391. doi:10.1089/jam.2006.19.385

64. Ali A, Scott JB. Lessons learned about aerosol administration in the COVID-19 era. Chest; 2021. Available from: https://www.chestnet.org/Topic-Collections/COVID-19/COVID-in-Focus/Lessons-Learned-About-Aerosol-Drug-Delivery-in-the-Era-of-COVID 19. Visited on September 14, 2021.

65. O'Malley California. Equipment cleaning and infection control in aerosol therapy. Respiratory care. 2015;60(6):917–927. doi:10.4187/respcare.03513

66. Tablan O, Anderson L, Besser R, Bridges C, Hajjeh R. Guidelines for the prevention of healthcare-associated pneumonia. Recommendations from the CDC and Healthcare Infection Control Practice Advisory Committee. MMWR Recommendations and Reports; 2004 [Updated March 26, 2004; cited January 19, 2009]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm. Visited on September 14, 2021.

67. Clean and disinfect the atomizer. Cystic Fibrosis Foundation; 2019. Available from: https://www.cff.org/Life-With-CF/Treatments-and-Therapies/Medications/Nebulizer-Care-at-Home/. Visited on September 14, 2021.

68. Kriegel M, Buchholz P, Gastmeier P, Bischoff P, Abdelgawad I, Hartmann A. The predicted infection risk of SARS-CoV-2 aerosol transmission. Medicine xiv. 2020. Available from: https://www.medrxiv.org/content/10.1101/2020.10.08.20209106v5. Visited on September 14, 2021.

69. Kupper M, Asbach C, Schneiderwind U, Finger H, Spiegelhoff D, Schumacher S. Test indoor air purifiers for particulate pollutants under realistic office conditions. Aerosol air quality resolution. 2019;19(8):1655–1665. doi:10.4209/aaqr.2019.01.0029

70. Pei J, Dong C, Liu J. Operational behavior and corresponding performance of portable air purifiers in residential buildings in China. Create an environment. 2019;147:473-481. doi:10.1016/j.buildenv.2018.08.009

71. Home care of COVID-19 patients with mild symptoms and management of their contacts. World Health Organization; 2020 [Updated May 14, 2020]. Available from: https://www.who.int/publications-detail/home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management Contact. Visited on September 14, 2021.

72. Fink J, Ehrmann S, Li J, etc. Reduce the risk of aerosol-related transmission in the COVID-19 era. J Aerosol Med Pulm Drug Deliv. 2020;33(6):300–304. doi:10.1089/jamp.2020.1615

73. Jensen MH, Cichosz SL, Hejlesen OK, etc. The clinical impact of home remote monitoring on patients with chronic obstructive pulmonary disease. Remote JE Health. 2012; 18(9): 674–678. doi:10.1089/tmj.2012.0003

74. Sanchez-Morillo D, Fernandez-Granero MA, Jiménez AL. Early detection of COPD exacerbations using daily remote monitoring of symptoms and k-means clustering: a pilot study. Medical bioengineering calculations. 2015;53(5):441–451. doi:10.1007/s11517-015-1252-4

75. Alrajab S, Smith TR, Owens M, Areno JP, Caldito G. The home remote monitoring program reduces the deterioration of COPD patients and the utilization of health care. Remote JE Health. 2012;18(10):772-776. doi:10.1089/tmj.2012.0005

76. Antoniades Nc, Rochford PD, Pretto JJ, etc. Pilot study of COPD remote monitoring. Remote JE Health. 2012; 18(8): 634–640. doi:10.1089/tmj.2011.0231

77. Fairbrother P, Pinnock H, Hanley J and others. Exploring the remote monitoring and self-management of patients with chronic obstructive pulmonary disease: a qualitative study embedded in a randomized controlled trial. Patient Education Committee. 2013;93(3):403–410. doi:10.1016/j.pec.2013.04.003

78. Ho TW, Huang CT, Chiu HC, etc. The effectiveness of remote monitoring of patients with chronic obstructive pulmonary disease in Taiwan-a randomized controlled trial. Scientific Reports 2016;6(1):23797. doi:10.1038/srep23797

79. Kim J, Kim S, Kim H, etc. The acceptability of consumer-centric u-health services for patients with chronic obstructive pulmonary disease. Remote JE Health. 2012;18(5):329–338. doi:10.1089/tmj.2011.0140

80. McDowell JE, McClean S, FitzGibbon F, Tate S. A randomized clinical trial on the effectiveness of remote monitoring of home care for COPD patients. J Telemedicine and telecare. 2015;21(2):80–87. doi:10.1177/1357633X14566575

81. Pedone C, Lelli D. COPD remote monitoring system review: update. Pneumonol Alergol Pol. 2015; 83(6): 476–484. doi:10.5603/PiAP.2015.0077

82. Reddel HK, Jenkins CR, Partridge MR. Self-management support and other alternative programs to reduce the burden of asthma and chronic obstructive pulmonary disease. Int J Tuberc Lung Dis. 2014;18(12):1396–1406. doi:10.5588/ijtld.14.0371

83. Venter A, Burns R, Hefford M, Ehrenberg N. The result of long-term care management services supported by telemedicine to support people with long-term illnesses at home. J Telemedicine and telecare. 2012;18(3):172-175. doi:10.1258/jtt.2012.SFT112

84. Burton C, Pinnock H, McKinstry B. Changes in physiological variables and symptoms remotely monitored before the deterioration of chronic obstructive pulmonary disease. J Telemedicine and telecare. 2015; 21(1): 29–36. doi:10.1177/1357633X14562733

85. Chatwin M, Hawkins G, Panicchia L, etc. A randomized crossover trial of remote monitoring of patients with chronic respiratory system (TeleCRAFT trial). Chest. 2016;71(4):305-311. doi:10.1136/thoraxjnl-2015-207045

86. Vianello A, Fusello M, Gubian L, etc. Home remote monitoring of patients with acute exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. BMC Pulm Med. 2016;16(1):157. doi:10.1186/s12890-016-0321-2

87. Elwyn G, Hardisty AR, Peirce SC, etc. Use remote monitoring to detect the deterioration of patients with chronic diseases: navigating the "trough of disillusionment." J Eval Clinical Practice. 2012;18(4):896-903. doi:10.1111/j.1365-2753.2011.01701.x

88. Martín-Lesende I, Orruño E, Bilbao A, etc. Remote monitoring of the impact of home care patients with heart failure or chronic lung disease from primary care on the use of medical resources (TELBIL Study Randomized Controlled Trial). BMC health service resources. 2013;13(1):118. doi:10.1186/1472-6963-13-118

89. Davis C, Bender M, Smith T, Broad J. The feasibility of the remote monitoring program after the acute transition period and the results of acute care utilization for underserved chronic disease patients. Remote JE Health. 2015;21(9):705-713. doi:10.1089/tmj.2014.0181

90. Fairbrother P, Pinnock H, Hanley J, etc. Continuity, but at what price? Remote monitoring of the impact of COPD on the continuity of care: a qualitative study. Prim Care Respir J. 2012;21(3):322-328. doi:10.4104/pcrj.2012.00068

91. Stoddart A, van der Pol M, Pinnock H, etc. Remote monitoring of chronic obstructive pulmonary disease: Cost and cost-utility analysis of a randomized controlled trial. J Telemedicine and telecare. 2015;21(2):108-118. doi:10.1177/1357633X14566574

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