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Acute asthma management considerations in children and adolescents during the COVID-19 pandemic
  1. Prasad Nagakumar1,2,
  2. Benjamin Davies1,
  3. Atul Gupta3
  1. 1 Respiratory Medicine, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
  2. 2 Birmingham Acute Care Research, University of Birmingham, Birmingham, UK
  3. 3 Respiratory Pediatrics, King's College Hospital, London, UK
  1. Correspondence to Dr Atul Gupta, Respiratory Pediatrics, King's College Hospital, London SE5 9RS, UK; atul.gupta{at}

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The perceived risk of nosocomial transmission of COVID-19 infection from administering nebulised therapies to patients with unknown infection status has generated plenty of debate.1 2 The absence of consensus recommendations and issues with availability of personal protective equipment (PPE) have resulted in health staff exploring non-nebuliser therapies for management of children presenting to emergency departments with acute wheeze/asthma. The Royal College of Paediatrics and Child Health (RCPCH) has raised concerns about children presenting late to the hospital, and it is imperative that asthma attacks are managed aggressively during the first hour of presentation. The risk to a child of an asthma attack is significant and can be fatal. Asthma attacks result in poor quality of life, missing home/school and the potential to adversely impact the child’s lung function trajectory.

Here we review the infection risks of viral aerosolisation from the nebuliser and the role of commonly used non-nebuliser therapies in acute childhood asthma in the context of the COVID-19 pandemic.

Nebulised bronchodilator therapy

The COVID-19 pandemic has resulted in stringent infection control measures, including use of full PPE while administering nebulised bronchodilators. Evidence of risk of infection spread by viral aerosolisation through a nebuliser itself is unclear.3 The advice from Public Health England (PHE) is that nebulisation is not a viral droplet-generating procedure: the droplets are from the machine (liquid bronchodilator drug particles), not the patient. The particles generated by the nebulisers are between 1 and 5 µm. The particle size is crucial for the lower airway deposition of the nebulised drug. An aerosol by definition comprises particles which remain suspended in air and are <10 µm in size. Under experimental conditions, the SARS-COV-2 virus has been shown to remain in aerosol for up to 3 hours.4 It is unknown if the nebuliser or cough during the nebuliser administration disperses the aerosolised virus …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Provenance and peer review Not commissioned; externally peer reviewed.