International expert opinion on the use of nebulization for pediatric asthma therapy during the COVID-19 pandemic

The main therapy goal for patients with asthma with or without COVID-19 is minimizing exacerbations and achieving asthma control (38). There are significant risks to a child suffering from a severe asthma attack and these attacks can result in fatal outcomes (34). Therefore, any deviation from planned, individualized asthma therapy, including nebulization, should be avoided wherever possible. Data on whether nebulized treatment represents an infection transmission risk for SARS-CoV-2 are limited. In light of the above, we advocate that nebulization should be continued during the COVID-19 pandemic but with appropriate safety precautions in the following patient populations: pre-school children, children who are currently receiving nebulization as part of their personal asthma plan, children who cannot operate an MDI plus spacer, in children with impaired asthma control when using the MDI plus spacer and those who present with severe exacerbations or are in respiratory distress (acute asthma/wheeze). In patients with suspected or confirmed COVID-19, it should be assumed that nebulization can transmit SARS-CoV-2 and therefore any personnel administering nebulization and any bystanders must use full PPE. It is imperative to individualize the risk-benefit assessment of nebulization. The risk posed by nebulization should be assessed by the treating physician who should perform a case-by-case risk assessment on an individual basis. HCPs should also consider individual needs, preferences and distinctive characteristics of local healthcare systems. Our recommendations were developed based on literature review and discussion of the evidence base as of March 2021. New data will continue to emerge during the COVID-19 pandemic. We do not anticipate data that would significantly change our recommendations, but we hope future studies will provide additional clarity on specific populations and situations. HCPs should monitor the literature to maintain awareness of data that may be relevant to their decision-making. Overall, our recommendation is that nebulization should remain the choice of treatment for children requiring this mode of treatment. We hope the safety measures discussed in this study will help guide treating physicians on best practice in pediatric asthma treatment during the pandemic, so that nebulization will not be withheld from patients in need.