Abstract
It was February 2020. I am finishing my 1-year sabbatical from the University of Alberta (UoA) and have started to do some consulting work in the pediatric pulmonology unit at the Dana-Dwek Children's Hospital in Tel Aviv. It is winter time here in Israel, yet the temperatures are not that cold; there is no snow but occasionally a foggy rain permeates everything.
Some rumors and news are starting to appear about some infectious disease called corona virus disease spreading in China. It seemed very remote and far away at that time. It is in China and it has nothing to do with us. It certainly will not arrive here. It is only there, far, far away.
Alibaba and some construction labor workers present here and there were the only Chinese-related things of interest to us. Jokes about the virus and the poor corona beer started to appear.
There are some news stories about a cruise ship named “diamond princess,” where the corona virus is spreading. Since there are some Israelis on the ship, the news about their situation is increasingly in our media and more and more people here are paying attention.
I am still on the mailing list of the UoA. In mid-February, one of the e-mails from UoA caught my eye. It was a memo from Alberta Health Sciences (AHS) reminding staff about the shift from nebulizers to metered-dose inhalers (MDIs) that occurred throughout Alberta as of 2017. The memo stated that nebulization with small volume nebulizers (SVNs) may be a risky procedure due to cross-infection or sensitization of staff and bystanders. They called for even more caution and more restriction on the use of nebulizers if a virus named corona should arrive in Canada.
For years I have been engaged in a lot of aerosol therapy-related research and have developed expertise in the field of aerosol medicine that has become a major interest and has resulted in several very useful device development projects in pediatric pulmonology. I have been happy to closely collaborate with Dr Michael Newhouse a world-renowned aerosol expert who has been and remains my mentor and dear friend.
For many years I have advocated for the use of MDIs instead of nebulizers for treating airflow obstruction and was quite frustrated that, despite so much evidence regarding their greater efficiency, simplicity, and overall cost benefit, particularly when combined with valved holding chambers (VHCs) in acute asthma, so many clinicians were still using SVNs, incorrectly thinking them better.
The AHS memo encouraged me in that, at last, there appeared to be support for replacement of SVNs by MDIs. Thinking about the rationale behind the memo, I started to agree that it had considerable merit. Nebulizers, especially the inexpensive SVNs commonly used in the Emergency Department (ED) and on hospital wards, may be associated with an increased risk of cross-infection, so why take this risk and use nebulizers in hospitals during these times?
This February 26, during a joint meeting of the National Societies for Pediatric Pulmonologists and Adult Pulmonologists in Israel, I took the podium for 2 minutes between lectures. I told the audience about the memo I had received from Canada and suggested that they consider this change in their practice in view of the potentially imminent arrival of the corona virus in Israel.
Not a single colleague in the audience responded. It seemed that none of them paid the slightest attention. The lectures continued.
During the next few days, corona virus disease 19 (COVID-19) arrived in Israel. Like everywhere else, it initially spread slowly and then exploded exponentially. Everyone was now talking about COVID-19 and there was universal fear and anxiety. Schools were closed and the whole country came to a halt. Regular work in hospital shifted toward and focused almost exclusively on COVID-19. Being a pediatrician however, there was, initially, not much for us to do. Most of the action was in the adult hospital departments and in the ED. As pediatricians we found ourselves with little “real” work to do. Initially, I felt somewhat “unnecessary,” with little to contribute.
However, I subsequently sensed that maybe I could contribute through my aerosol expertise. I started giving talks that attempted to convince practitioners to shift aerosol therapy from SVNs to MDIs. Increasingly, I realized this could be a meaningful and urgent mission for me due to reports of rapidly increasing morbidity and mortality from all over the world with a major risk for health care workers.
My initial efforts were accepted with very little enthusiasm due, in my view, to widespread ignorance regarding aerosol therapy in my hospital.
I spoke with infectious disease and ED experts and other professionals about the increasing evidence-based need to avoid nebulizers, yet this idea was received with little enthusiasm. I wondered whether it was, perhaps, the old idea about teaching old dogs new tricks!
My frustration increased even more rapidly than the increase in COVID-19–related problems! I became more and more anxious about the welfare of colleagues in hospital and families at home who were probably continuing to disseminate the virus during SVN therapy. I tried to convince my colleagues and senior administrators about what I perceived as a missed opportunity to reduce the danger of infection among hospital employees and their patients!
It then dawned on me that nothing less than a scientific publication in a peer-reviewed journal was likely to convince them. So Newhouse and I wrote an article as a letter to the editor of the CMAJ that was accepted for publication and appeared online on March 3. It was one of the first publications that stressed that something needed to be done urgently about dissemination of COVID-19 by SVNs. And it indeed had a remarkable impact. I received numerous responses from all over the world including from an orphanage in Nepal. Over the next couple of weeks, I was able to convince the, previously somewhat indifferent, Israeli Society of Pediatric Pulmonology to issue a position article about the SVN issue and the adult pulmonology society followed suit a couple of days later.
My daughter had a good contact with the Ministry of Health (MOH) deputy general manager's secretary. After endless “WhatsApp” and phone conversations with her, we persuaded her to receive the relevant materials from me and bring them to the attention of the director. I spent a week on the phone with the secretary making sure the issues were fully understood and discussed.
The MOH director assembled a committee to discuss the matter. I managed to communicate my views and opinion to them and every night I was informed about the intense discussions of the committee and its progress.
Would they agree to issue a directive? Tension was high and I felt as though the outcome had become one of the most important projects of my career.
On March 29, a “WhatsApp” message arrived: “It is approved! A directive is being developed and would soon be publicized.” The following morning a nationwide directive was distributed to all public health facilities and hospitals in Israel. It was highly recommended that nebulizers should be restricted only to “special circumstances” and that MDIs should replace them to deliver aerosol medications.
The trek was over. The directive had its impact and I felt relieved and vindicated. There were more consequences—all over the world various pulmonology organizations issued similar recommendations and so many people rapidly switched from SVNs to MDIs plus VHCs that a transient shortage developed as MDI and VHC prescriptions soared.
The concept that I initiated in Israel was, for the most part, accepted worldwide.
The move away from SVNs during the COVID-19 epidemic was secondary to the acute fear and sense of urgency of most people. Sometimes we need to “act without definitive evidence, just in case all hell breaks loose, according to the precautionary principle.” The precautionary principle can be defined as, “a strategy for approaching issues of potential harm when extensive scientific knowledge on the matter is lacking” (Wikipedia). Recently, I decided to review all the relevant literature and to carry out a careful evidence analysis. From the initial preliminary search, it seems that there is indeed considerable lack of knowledge about the potential for cross-infection risk posed by SVNs and there is a lot that still needs to be studied.
Meanwhile, I may not have treated any COVID-19 patients, but I feel that I have made a modest contribution to the fight against the pandemic. Under the circumstances, I am fortunate to have had aerosol expertise that enabled me to make an important contribution to the management of the COVID-19 epidemic.