Inhaled and nebulized therapy in COVID-19: an evidence-based update

SARS-CoV-2 transmission occurs primarily through inhalation of aerosols indoors, reigniting the debate about the safety of inhaled therapy and nebulization. A distinction must be made between patient bioaerosols and medical aerosols. Nebulization can increase ambient particles through fugitive leaks or secondhand exposures, but the risk depends on the viral load, proximity between the patient and healthcare personnel, exposure time, and room ventilation. Detection of RNA in the air is rarely accompanied by culturable virus. Fugitive emissions vary by nebulizer, interface, and leaks, and are reduced by filters, valves, ventilation, use of personal protective equipment (PPE), hygiene, and education. Inhaled therapy should not be automatically discontinued; it should be individualized.