Delivering Respiratory Care Without Spreading "Bugs"

The following article was originally published in Preventing Infection in Ambulatory Care, the quarterly e-publication from the Association for Professionals in Infection Control and Epidemiology (APIC). To learn more about receiving this resource and joining APIC, visit To learn more about APIC, visit


Healthcare delivered in the outpatient setting continues to increase in volume and complexity at a dizzying rate. Because of innovations in both diagnostic and therapeutic modalities, respiratory therapy services are being provided in outpatient settings that historically were only provided in the hospital. These settings cover a broad spectrum and can include the physician's office, the pediatric clinic or the pulmonology department in a medical specialties clinic. Outpatient respiratory therapy ranges from spirometry and nebulization treatments, to home sleep studies and intensive pulmonary rehabilitation. Various healthcare workers may be responsible for different components of this care including medical assistants, certified nursing assistants, licensed practical nurses, registered nurses and respiratory therapists.


Use Precautions for Every Patient

Proper respiratory precautions must be applied with all patients.[1] Even though most respiratory conditions seen in your facility may not be infectious, every clinic and physician's office should have a plan to minimize and prevent respiratory pathogen spread. Multiple strategies can be employed, including entrance signs that encourage patients to cover their coughs. Masks, tissues, and waterless hand hygiene products should be readily available for patient use. Freestanding hand hygiene and respiratory etiquette stations accompanied by large posters can be posted at entrances to facilities or departments.


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Additionally, the coughing patient should be escorted to an exam room as soon as possible to minimize or eliminate possible infection transmission to others in the waiting area. Be aware that patients with a chronic cough due to a respiratory disease process such as asthma or COPD can have a concurrent transmissible respiratory infection that may not have been identified. "Cover your cough" instructions also apply to these patients. All healthcare workers should feel comfortable handing either tissues or a mask to their coughing patients.


All healthcare workers should also have ready access to masks and hand hygiene supplies, including conveniently-placed dispensers of waterless alcohol-based hand antiseptics. A helpful resource that covers this in detail is Updated CDC Influenza Infection Control Guidance 2010-2011 Influenza Season. (


Dealing with Devices

In addition to establishing a robust respiratory etiquette program, the infection preventionist (IP) should focus attention on devices used to deliver the respiratory therapy. The first step to preventing infection via respiratory equipment is consulting the manufacturer's recommendation for the cleaning and disinfection of every device used for treatment. Many times these instructions have two parts; the first part is guidance for the patient's at-home use and the second is written for the healthcare worker. If a device only has home-use instructions, the IP should be alerted to the possibility that this is a "single patient use" device and should investigate further. Don't confuse single patient use devices with single use or disposable devices. The manufacturer usually includes a statement about the appropriate use of the device in the packaging. If the packaging cannot be found, the IP should contact the manufacturer to obtain written guidance.


Single patient use devices must never be used by multiple patients. Even if this is a practice that has occurred in the past, it is not considered safe and puts the patient at risk. Because it is both difficult and impractical to clean and disinfect the interior surfaces of a reusable spirometer between patients, a disposable one-way valve mouthpiece should be used. These mouthpieces allow the patient to only exhale into the device, not inhale. These can only be used for performing exhalatory spirometry and peak flow measurements.


For inhalation and exhalation spirometry, disposable micro-aerosol filters inserted at the end of the spirometer should be used. These filters minimize the risk of contamination of the spirometer from exhalation and the subsequent risk of disease transmission with inhalation. They also protect the internal surfaces of the spirometer from moisture and from cleaning agents and disinfectants. The exterior parts of these devices should be cleaned and disinfected between each patient with a disinfectant wipe. Make sure that all disposable filters comply with the device manufacturer's guidance.


It's also important to always stress the importance of performing hand hygiene before and after any type of respiratory therapy. While reusable devices in the hospital setting are commonly sterilized or high-level disinfected — many times through a pasteurization process — this is not always practical or even feasible in the outpatient setting. If a reusable device requires sterilization or high-level disinfection, meticulous cleaning is always required first. If a device can tolerate steam sterilization, this is usually the safest and most cost effective practice.


However, if steam sterilization is not recommended, high-level disinfection might be. Remember to follow the manufacturer's recommendations for the reprocessing of all reusable devices. However, keep in mind that sometimes the manufacturer — rather than recommending a specific process, i.e. sterilization or high-level disinfection — will recommend a product, such as a specific high-level disinfectant. If this is not a product that is currently used at your facility and would require a significant change, clarify this difference with the manufacturer. It may be that the manufacturer has a very specific and important reason for recommending a specific product. However, if they do not object to a proposed product substitution, request their approval in writing for the substitute product.


Never substitute a lower level process such as intermediate-level disinfection for high-level disinfection. Alternatively, consider substituting a disposable device for one that is reusable, as this might be the more cost effective and the safer approach for the patient and the healthcare worker. Using a dishwasher for these reusable respiratory therapy devices is not considered an acceptable substitute for either sterilization, or pasteurization/high-level disinfection. After disinfection, the device should only be rinsed with sterile water, not tap water because it can harbor microorganisms that could cause pneumonia.[2] Cleaning and disinfecting tubing used in respiratory therapy is difficult in most outpatient settings; most of this tubing is now disposable.


Another common respiratory therapy that occurs in the physician's office is delivery of medication via a nebulizer, either in-line or hand-held. Aseptic technique should be used for dispensing the medication, which should always be sterile. Using medication in single use-dose vials is a safe and recommended practice. If sterile saline solution is required for this therapy, it should be without preservative or buffering agents. It is best to use sterile saline supplied in single dose plastic "bullets" or "pillows" formulated specifically for respiratory applications. Most outpatient settings use disposable nebulization equipment attached to an oxygen source.


It is a challenge for the IP to stay current on all respiratory therapy modalities and their attendant devices. Request to be notified when a process is changed or a new piece of equipment or a device is introduced in the department. If there is a product review committee in your organization, participation in this committee usually means that you have input when new respiratory therapy equipment is being considered or introduced. You might very well be the only one in your department or clinic who is asking, "How can we ensure that the use and care of this device will not lead to infection?"



1. Updated CDC Influenza Infection Control Guidance 2010-11 Influenza Season. Available at: Accessed 03/13/2011.


2. Centers for Disease Control and Prevention. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR. 2004;53(No. RR-3):1-36.


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