Nebs, Trachs, Vents, Suctioning, and the Spread of COVID-19

There have been a lot of questions among families of children who are medically complex about the safety of respiratory devices and COVID-19. To begin with, we want to make clear that children who use nebs, have trachs, use vents, or are suctioned are NOT at higher risk of contracting COVID-19 simply by using those devices. Instead, these devices, if used by someone who IS infected, may spread the infection to others nearby.

Many children who are medically complex use a variety of these respiratory devices, which could possibly contribute to the spread of COVID-19. This article will review some of these devices, how they may spread COVID-19, and provide suggestions that may help reduce the risk.

Aerosol-Generating Procedures and Devices

A number of respiratory devices and procedures are considered to be “aerosol-generating” and may increase the spread of viral particles in a virus like COVID-19. Aerosol-generating means that these devices or procedures may release particles into the air that contain COVID-19, which can be breathed in by others or land and contaminate surfaces. Some common aerosol-generating procedures and devices used in home care include:

  • Non-invasive ventilator use with a mask, especially if it has a significant leak, including CPAP and BiPAP
  • Ventilator use with a tracheostomy, especially with a significant leak
  • Ventilator exhalation limb, valve, or port
  • Ventilator circuit changes
  • High-flow oxygen use
  • Tracheostomy procedures such as replacing the trach
  • Open suctioning
  • Cough assist device use
  • Nebulizer use, especially via mask
  • Trach mist collar use

In general, the lower the flow, the less moist, and the more closed the system, the less likely particles are to be released into the environment. So, for example, regular flow oxygen use is low risk because the oxygen is lower flow into the nose. On the other hand, using a nebulizer or ventilator is higher risk because the air is typically at a higher pressure and humidified.

Who is at Risk?

If your child requires these procedures or devices, he or she is NOT at higher risk simply due to the aerosol-generating nature of the procedure or device. In addition, if your child is not sick with COVID-19, there is no risk of spread. Note, however, that it is not always easy to know when a child is infected since children may be infected and contagious even without symptoms.

If your child DOES have COVID-19, performing these procedures may make it more likely that COVID-19 will spread to other family members or nurses in the home. In addition, if another family member or friend also requires one or more of these procedures, that individual may spread COVID-19 to your child.

Most importantly, know that if these procedures are performed in public settings such as schools or medical clinics, they may spread the infection widely. Since COVID-19 likely can survive on surfaces, the spread may continue even after you have left the area.

Should We Make Changes?

In almost all cases the benefits of the procedure or device outweigh the risks of stopping it. However, there are some ways to mitigate the risks, especially if you have multiple at-risk people in your home. Below we list some general suggestions as well as device and procedure-specific suggestions that may reduce the spread of COVID-19. Talk to your medical team about their recommendations for you and your family based on your child’s unique needs.

General Suggestions
  • Keep children with trachs, vents, oxygen, and other respiratory equipment at home during the course of the pandemic, primarily for their own safety, but also to minimize spread.
  • If you must take your child to a medical clinic or other public place, it is best not to perform procedures such as neb treatments, suctioning, or cough assistance in public, especially if you suspect your child might be sick. Alternatives include bringing your child back to the car or home for procedures, or asking the hospital or clinic if there is a separate room (a negative-pressure room is preferred) your child can use for procedures.
  • When at home, perform procedures such as trach changes, cough assistance, suctioning, and nebulizer treatments in a separate room with a closed door whenever possible.
  • Use personal protection equipment, such as mask and gloves, during procedures.
Suggestions for Trachs
  • Treat the trach like you would the nose and mouth in terms of infection control.
  • Consider using a cuffed trach to reduce aerosol generation.
Suggestions for Ventilators
  • Consider using a cuffed trach or reduce the leak around the trach to reduce aerosol generation.
  • For non-invasive ventilation, use a well-fitting, tight mask to reduce the leak.
  • Avoid opening or disconnecting the circuit as much as possible.
  • Make sure all filters are in place and in good condition.
  • Hospitals are currently adding HEPA filters to various parts of ventilator circuits and the ventilator itself, including exhalation ports, valves, or limbs of personal ventilators. It may be possible to do the same in the home situation.
Suggestions for Suctioning
  • Use a closed suctioning system if possible, particularly for children with trachs and vents.
  • Make sure all filters on suction machines are in place and in good condition.
  • Keep the suction system clean and disinfect the canister and tubing with 50%hydrogen peroxide/water or equivalent daily.
  • Don’t reuse sterile suction catheters.
Suggestions for Cough Assist Devices
  • Use a well-fitting mask to reduce the leak.
  • Clean the mask daily.
Suggestions for Nebulizer Use
  • Consider using an inhaler (MDI) instead of a nebulizer to administer medication.
  • If the child is on a ventilator, administer the neb inline.
  • Clean all disposable neb parts daily.
Suggestions for Trach Mist Collars
  • Consider switching to an HME instead if possible.
  • Consider using a room humidifier instead of a trach mist collar.

Additional Resources

Author: Susan Agrawal • Date: 3/23/2020
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