Better Nebulizer Hygiene Possible With Training for Patients, Caregivers

Too often, cystic fibrosis (CF) patients or their caregivers do not follow proper hygiene procedures when cleaning, disinfecting and storing nebulizers, risking them being a source of lung infections. But proper training can help, a Turkish study reports.

Healthcare providers should also be more aware of the potential for poor nebulizer hygiene, and promote education that supports good habits, its researchers recommended.

Their study, “The effects of nebulizer hygiene training on the practices of cystic fibrosis patients and caregivers,” was published in the journal Pediatric Pulmonology.

Nebulizers are a key component of CF treatment, as they allow the delivery of therapies directly to the lungs. Their ability to be used in the home also allows for better symptom control and lessens treatment burden.

Using these devices outside of a sterile hospital environment, however, increases the risk of their contamination by micro-organisms that promote lung infections.

The Cystic Fibrosis Foundation has published and updated guidelines, called Infection Prevention and Control (IPC), that include those for at-home care of nebulizers. Problems can occur if these practices are not known or followed.

Under IPC guidelines, nebulizers should be dismantled and then cleaned in solutions like ethyl alcohol followed by rinsing with sterile water only if a “cold” approach is taken. Under a “hot” approach, the nebulizer’s parts are placed in boiling water or in a microwave for five minutes (or the like). Air drying should follow either approach.

Proper nebulizer care is particularly relevant for CF patients, as they are susceptible to lung infections. Despite being generally aware of the importance of nebulizer hygiene, however, patient and caregiver adherence “to recommended cleaning and disinfection practices are highly variable, ranging from 15% to 90%,” the researchers wrote.

Reasons for this failure range from a lack of “thorough knowledge” of the specifics steps in these guidelines, to the burden of following them after each use, they added.

As such, training programs may have a key role in improving patient compliance to safe practices. “One of the leading causes of poor compliance to hygiene procedures is lack of standardized educational programs,” the scientists wrote, adding that studies into educational interventions on such care are lacking.

To better understand the extent of CF patient and caregiver knowledge are about nebulizer hygiene, their adherence to IPC guidelines, and to assess the effects of an education program on their nebulizer cleaning and disinfection habits, the research team organized a single-site study.

Their study enrolled 173 CF patients — 4 months to 30 years old, all being followed at Marmara University CF Center — and their caregivers. All relied on reusable jet nebulizers for treatment delivery, and most patients (75.1% or 130 people) had evidence of bacterial colonization in respiratory samples taken.

Patients older than 18 (22 people) and all caregivers were first asked to answer a questionnaire that covered their knowledge of infection prevention, the frequency of their nebulizer cleaning and disinfection, and the methods used. Participants were not informed about the questionnaire prior to it being given.

A five-point Likert scale — often used in questionnaires to evaluate the strength of a respondent’s agreement or disagreement with a statement — was used to evaluate participants’ perception of the importance of at-home nebulizer cleaning and disinfection.

Results showed a mean Likert scale score of 4.95, indicating awareness, the study reported.

Questionnaire responses also showed that 85% of caregivers and patients were “using inappropriate methods for nebulizer cleaning,” and only 52% were properly storing the nebulizer between use.

This questionnaire was followed by a one-hour educational session, including pictures and videos regarding the CFF’s guidelines on nebulizer use and hygiene. Participants were also invited to watch augmented reality pictures regarding nebulizer hygiene via a cellphone app.

One to three months after the educational session, these caregivers and patients completed the same questionnaire during a routine visit to the CF center.

Researchers now observed that the number of participants reporting to clean their nebulizer after each use rose from 58.4% prior to training to 78% with training. “Cleaning before disinfection is an important process, since organic and inorganic debris makes the disinfection less effective or even ineffective,” the researchers wrote.

Post-training, the number of people reporting “inappropriate” cleaning and disinfection also dropped to 22.5% (from 85% in the pre-training questionnaire).

Likewise, the number of participants who disinfect as well as clean their nebulizers rose from 33.6% pre-training to 75.7% after training.

Researchers also found that 80% of these CF patients were using their nebulizers longer than the recommended duration of about six months.

Prolonged use can cause damage to the nebulizer, which makes cleaning and disinfection methods less effective, increasing the risk of contamination, they wrote.

Overall, the study showed a training session was highly effective in improve the rate of proper hygiene practices. Patients’ awareness of the guidelines is essential for optimal adherence, and clinicians should also be aware of the problem and better educate patients in their care, the researchers wrote.

“The necessity of cleaning, disinfection, careful drying, correct storage of the nebulizer parts and changing the nebulizer equipment within recommended time should be emphasized to CF families regularly,” the team concluded.

These scientists are planning to continue to follow these people, to judge the long-term effects of training on hygiene practices. One of the study’s limitations, they said, is that it relied on self‐reported care of nebulizers rather than on objective assessments.