To NUK or not to NUK

[The Dot]

Hi,

I am new to the site. I joined to get some insight from those of you who will know the most about the CF questions I may have. I am a registered respiratory therapist who has been in the field over 20 years. I have been helping to establish my workplace as a hospital which specializes in the care of adult CF patients. We started off using cold sterilization to disinfect the reusable nebulizers we give the CF patients for their Pulmozyme and also for their inhaled antibiotics. However, we are having to use a lot of alcohol, and now we have learned that we cannot store a lot of alcohol without building a special type of storage area to keep it safely separated from our storage of oxygen tanks. So, now we are considering going to heat sterilization. I always hear that everyone has a NUK at home because this is the unit that was provided by the CF Pharmacy (?I think?). I was just wondering if you all could give me some feedback about the NUK and/or any other steam sterilizers you have used. About how long do they last? Is there a smaller unit that will not take up a lot of space in an already crowded hospital room? Are there any inherant problems with heat sterilization (other than melting nebs that are not meant to be heated).
I appreciate your help - you will be contributing to something that will make the care of adult CF patients better as we go down this road together, so thanks in advance!!!

 

[Aboveallislove]

I know there was a discussion of using baby sterilizers on here before (you might be able to search) and some concern over research saying it might not be good enough. Our hospital only uses disposable nebs and frankly I wouldn't have our son (not an adult, obviously) use ones in a hospital sterilized that way. May I ask why you don't use disposable ones? Thanks so much for reaching out to those you help!

 

[The Dot]

I know there was a discussion of using baby sterilizers on here before (you might be able to search) and some concern over research saying it might not be good enough. Our hospital only uses disposable nebs and frankly I wouldn't have our son (not an adult, obviously) use ones in a hospital sterilized that way. May I ask why you don't use disposable ones? Thanks so much for reaching out to those you help!

We use disposable nebs for albuterol, budesonide and hypersal, but the specialty nebs that we use for Pulmozyme and antibiotics cost at least 10 times as much as the disposable nebs. We are just trying to be good stewards, while providing for all of the patients' needs. Don't worry, the sterilized nebs are only used by the same patient, not bulk sterilized and passed randomly to patients.

 

[believingjesus]

Hi The Dot! I appreciate that you are trying to improve your workplace and come here for any advice. Things have really changed since my son was growing up. When he was hospitalized in 2007 they put his neb in a bag by his hospital bed when he was done using it and saved it for the next time. I asked at that time if they could please boil it and they said that they did not have any way to do that and the hospital could not afford to give him a disposable one each time even though they charged our insurance greatly for that hospital stay. Things sure have changed over the years but I wish they would have known more back then too. I think hospitals should boil the nebs or use disposable ones or place the nebs in isopropyl alcohol for at least 5 minutes as is recommended by the Cystic Fibrosis Foundation. My son only uses Pari nebs for everything. We just ordered some more recently and now he has about 15 Pari nebs as he travels alot, of course our insurance only covers one every 6 months so I pay for that for him to help him.

 

[Gammaw]

Welcome Dot! I think it's great that you've joined us to ask questions of those who most affected by your decision. I hope you hang around our site for a long time as you care for CFers. I was uncertain from your post whether you were part of a new approved CF Center, or simply a hospital that cares for CF patients periodically and want to do your best! Either way, I would expand on believing's response - there are guidelines in place drafted by the Cystic Fibrosis Foundation that will give you the recommended options for sterilization. Here's a reprint from what I believe are the most recent guidelines, the 2013 update. You can find the entire set of Guidelines at http://www.jstor.org/stable/10.1086/676882. There is a bit of a difference between the recommendations for institutional care of nebulizers and home care of nebulizers. I would also suggest you contact the Cystic Fibrosis Foundation as well as a Cystic Fibrosis Center in your State to discuss the most cost effective way they manage to adhere to the Guidelines. Thank you so much for asking for help on this!

Care of Nebulizers in the Hospital
47. The CF Foundation recommends the following:

• a. Nebulizers are for single-patient use only
  
• b. Aseptic technique is always followed when handling the nebulizer and dispensing medications
  
• c. Single-dose vials of medication used in nebulizers are always preferred
  
• d. Handheld disposable nebulizers are managed as follows:
  
  • i. After each use, rinse out residual volume with sterile water and wipe mask/mouthpiece with an alcohol pad
    
  • ii. Discard the nebulizer every 24 hours
• e. Handheld reusable nebulizers (eg, home equipment) are managed as follows:
  
  • i. After each use, clean, disinfect, rinse with sterile water (if applicable, following cold disinfection method), and air dry away from sink
    
  • ii. After each use, the nebulizer can be reprocessed (eg, by steam sterilization) if the reprocessing is performed according to the manufacturer’s instructions and the CF Foundation recommendations for home care (rec. 59) and if the nebulizer can be returned to the patient in time for the next treatment

Source of supporting evidence: 2003 CF IP&C guideline, Category II; 2003 pneumonia guidelines, Category IB; 2008 sterilization and disinfection guidelines, Category IB



The recommendations for home care referenced above "(rec. 59)" is reprinted below:

Nebulizers: Cleaning and Disinfecting
59. The CF Foundation recommends that the following steps be performed for nebulizers used in the home as soon as possible after each use:

• a. Clean the nebulizer parts with dish detergent soap and water
  
• b. Disinfect the nebulizer parts using one of the following methods:

Heat methods:

• a. Place in boiling water and boil for 5 minutes
  
• b. Place in a microwave-safe receptacle submerged in water and microwave for 5 minutes
  
• c. Use a dishwasher if the water is more than or equal to 70°C or 158°F for 30 minutes
  
• d. Use an electric steam sterilizer

Cold methods:

• a. Soak in 70% isopropyl alcohol for 5 minutes
  
• b. Soak in 3% hydrogen peroxide for 30 minutes
  
  • i. Rinse off the cold-method disinfectant using sterile water, not tap water; the final rinse must be with sterile or filtered (less than or equal to 0.2-micron filter) water
    
  • ii. Air dry the nebulizer parts before storage

Source of supporting evidence: 2003 CF IP&C guideline, Category II
2013 CF IP&C guideline consensus: 100%
Sections in the text: III.D.1; IV.E.3

60. The CF Foundation recommends that nebulizers used in the home should not be disinfected with acetic acid (vinegar), bleach solutions, or benzalkonium chloride (eg, “Control III”).
2013 CF IP&C guideline consensus: 100%
Sections in the text: IV.E.3

 

[Gammaw]

Hi Dot. Here's the link to this forum's discussion on the effectiveness of baby bottle sterilizers. I hope we've helped!

http://forum.cysticfibrosis.com/threads/67666-Sterilizing-with-an-Avent-steam-sterilizer

 

[Oboe]

When I'm in the hospital, everything they give me is in disposables and they just switch 'em out every couple days or so. Then if I have to bring something like my Cayston neb, they give me some solution to soak it in. Though, I have used a baby bottle sterilizer and it's pretty easy to use and would be easy to keep in a patient's room if you went that way.

 

[Aboveallislove]

We use disposable nebs for albuterol, budesonide and hypersal, but the specialty nebs that we use for Pulmozyme and antibiotics cost at least 10 times as much as the disposable nebs. We are just trying to be good stewards, while providing for all of the patients' needs. Don't worry, the sterilized nebs are only used by the same patient, not bulk sterilized and passed randomly to patients.

Thanks so much for the clarification...I was thinking you meant bulk sterilizing! It makes me wonder though as when our son was hopsitlized they used the same type of disposable for his Pulmozyme and other meds.

Also, so sorry if my response was "short." I was being short--but not at you--just trying to rush with an answer as I needed to finishes my 5 year olds treatments and school. I meant to come back and point you to more info then saw Gammaw's excellent response!!!
Good luck and thanks again for your concern for CFers!

 

[The Dot]

Thanks so much for the clarification...I was thinking you meant bulk sterilizing! It makes me wonder though as when our son was hopsitlized they used the same type of disposable for his Pulmozyme and other meds.

Also, so sorry if my response was "short." I was being short--but not at you--just trying to rush with an answer as I needed to finishes my 5 year olds treatments and school. I meant to come back and point you to more info then saw Gammaw's excellent response!!!
Good luck and thanks again for your concern for CFers!

Absolutely - no offense taken whatsoever! Thanks for the info!!!

 

[The Dot]

Do you find that the steam in the room from the sterilizer is bothersome? We are in Houston and the rooms are hard to keep cool in the summer time.

 

[The Dot]

Gammaw,

Thanks for the great information. We are affiliated with Baylor Adult Cystic Fibrosis Center, so they have been very helpful, but I do not think you can be over-informed on this topic. Thanks again!