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Breathing space: Doctor concerned about COVID-19 protocol for children's asthma

Dr. Harvey Miller, an Islip doctor who specializes

Dr. Harvey Miller, an Islip doctor who specializes in asthma, is sounding the alarm on a recent CDC recommendation that inhalers should be used instead of nebulizers in schools if a child needs asthma treatment. Credit: Barry Sloan

An Islip doctor who helped author a state law that led to greater availability of nebulizers to treat asthma in schools said he is concerned that new federal guidelines, favoring specially adapted inhalers to reduce potential COVID-19 risk, could make the devices less available for children.

Allergy and asthma specialist Dr. Harvey Miller says he has written to health officials asking them to clarify rules for children in schools who may depend on nebulizers when other breathing aids that are less effective can’t be used.

"I don’t want people to be scared to use a nebulizer," Miller said.

Other doctors, however, believe inhalers are just as effective as nebulizers.

Concern over nebulizers stems from the belief that they can aerosolize exhaled breath into the open air as a patient is breathing in medication to open up airways, potentially spreading COVID-19, Miller said.

The Centers for Disease Control and Prevention’s website states that while it’s "uncertain whether aerosols generated by nebulizer treatments are potentially infectious," asthma treatments using inhalers with special adapters called spacers are "preferred." The CDC notes that asthma is one of the most common long-term diseases affecting children.

Nebulizer treatments at schools, the agency said, should be "reserved for children who cannot use or do not have access to an inhaler."

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Jonah Bruno, of the state Department of Health, said New York’s K-12 COVID-19 guidance "does not prohibit the use of nebulizers for children with asthma, but it recommends that schools work with the students’ health care providers on alternate asthma medication delivery systems."

If a nebulizer is used, he said, the guidelines said health care workers must wear appropriate personal protective equipment.

Asthma impacts a person’s lungs, causing wheezing, shortness of breath and coughing. In the U.S., about 5.5 million children under the age of 18 and 19.2 million people 18 and over have asthma, according to the CDC.

During an asthma attack, the body’s airways are restricted, making it difficult to breathe. Nebulizers transform liquid bronchodilator medicine into mist, and the patient breathes it in through a mask or a mouthpiece.

Patients also can breathe in a puff of medicine with personal inhalers known as metered dose inhalers, or MDIs.

"Both devices, the MDI and the nebulizer, have been shown equally efficacious in the treatment of asthma, as long as patient technique is correct," said Dr. Susan Schuval, division chief of Allergy and Immunology at Stony Brook Children’s Hospital. "In our allergy clinics at Stony Brook Children’s Hospital, we review the use of MDI with spacer and nebulizer at each patient visit to ensure that patients are using these devices optimally."

Schuval said inhalers are frequently prescribed with spacers that make it easier to inhale the medication and ensure optimal delivery of medication to the lower airways.

"Most people are familiar and comfortable with inhalers," she said. "Even in medical settings, we are not using nebulizers."

Young children are usually prescribed spacers with face masks, whereas older children use spacers with mouthpieces, Schuval said. She said so far this season the hospital is seeing less asthma flare-ups because more people are staying home and wearing masks.

"We use inhalers in our emergency department for asthma, rather than nebulizers. So, there is no concern on having children in school use inhalers rather than nebulizers," said Dr. Mitchell Grayson, chairperson of the Asthma and Allergy Foundation of America’s Medical Scientific Council and a physician scientist who specializes in pediatric allergy, asthma and immunology at Nationwide Children’s Hospital in Ohio.

"I would recommend this even in the absence of the pandemic. Other than for infants, I don’t prescribe nebulizers," he added.

But Miller said he has found nebulizers are considerably more effective in getting medicine to the lungs of asthma sufferers to open airways quickly, much more so than portable inhalers, and particularly in emergency cases.

Much of the medicine from doses of inhalers winds up in the mouth and throat of users, Miller said, a concern that prompted the nebulizer law and popularized the use of spacers, which keep the medicine in a clear container attached to a mask. Exhaled air remains in the chamber.

He also suggested exploring the use of high-efficiency particulate air, or HEPA, filters with nebulizers to see if that reduces COVID-19 transmission risk.

Assemb. Steve Englebright (D-Setauket), who sponsored the legislation to expand school nebulizers, said he believes Miller’s concerns should be thoroughly studied, noting that many of the emergency uses for which the law was written take place outdoors, on playing fields, where "I would imagine [aerosolizing] would be less of a problem."

"I don’t doubt there’s a way to solve the problem once it’s been identified," said Englebright, noting that while he’s not an expert on asthma, he relies on experts like Miller, who he said is "very thorough and does his homework."

A specific protocol should be crafted to address the treatment of asthma, and cases of respiratory distress, for children who cannot use portable inhalers or inhalers with spacers, Miller said.

Miller said he knows all too well the situations that can lead to asthma distress. He is on call 24/7 to help treat patients, and was instrumental in the passage of a 2015 state law that allowed children to carry portable nebulizers anywhere on school grounds to self-apply the breathing medication, or to do so with properly trained school nurses or others.

"We need to work all this out in the schools, in New York and nationwide," Miller said.

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