Health and Safety Practices Survey of Healthcare Workers

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Aerosolized Medications

Here you will learn what we found regarding aerosolized medications and about guidance to reduce exposure.


Aerosolized medications treat a variety of respiratory diseases, including respiratory infections. They are typically administered to patients using a nebulizer or other type of aerosol generator, such as a metered dose inhaler. Occupational exposure to aerosols may occur during treatments. Despite their benefits to patients, aerosolized medications may pose an occupational health hazard to respiratory therapists and other healthcare workers who administer them.1

Adverse health effects associated with exposure to the aerosolized medications targeted in this survey have been linked to:

  • Ribavirin and pentamidine – adverse reproductive effects2,3
  • Amikacin – respiratory irritation and kidney toxicity4
  • Colistin – asthma and labored breathing5
  • Tobramycin – asthma-like symptoms6

This study was conducted to assess adherence to best practices for minimizing exposure to these aerosolized medications. Analysis focused on (1) pentamidine, classified as a hazardous drug at the time of the survey, and (2) antibiotics amikacin, colistin and tobramycin, which lack authoritative safe handling guidelines. We were not able to assess ribavirin due to a relatively low number of ribavirin respondents. This might perhaps have been the result of severe Respiratory Syncytial Virus (RSV) cases requiring treatment with aerosolized ribavirin occurring outside of the 7-day window assessed by our questionnaire.

Best practices and study findings

Overall, findings from this survey show that adherence to exposure control and practice guidelines for pentamidine was not universal, and best practices were not fully utilized to minimize exposure to the antibiotics amikacin, colistin and tobramycin.

Although the antibiotics included in this study lack authoritative safe handling guidelines, prudence dictates that appropriate exposure controls be used to minimize exposure to them. Healthcare employers and employees share responsibility for ensuring that precautionary measures (see below) are taken to keep exposures to all aerosolized medications as low as possible.

What we found What employees should do
22% of respondents did not always wear protective gloves, 69% did not always wear protective gowns, and 49% did not always wear respiratory protection while administering aerosolized pentamidine to patients. Wear protective gloves and gowns to avoid any skin contact with pentamidine, and wear appropriate respiratory protection during activities where pentamidine aerosols are generated.7
4% of respondents said that they never used an aerosol delivery device equipped with an expiratory filter Use aerosol delivery devices equipped with an expiratory filter to minimize inhalation of aerosolized pentamidine8

Comparative practices for respondents who administered pentamidine vs antibiotics

  • Respondents who administered pentamidine were more likely to be trained, to be familiar with employer standard procedures, to have engineering controls in place, and to use eye/face protection and respirators than those who administered antibiotics.
  • Differences in reported reasons for not using PPE by respondents who administered pentamidine versus antibiotics may be attributable to the presence of safe handling guidelines for hazardous drugs, which applied only to pentamidine.
  • The major barriers to using PPE for those who administered pentamidine and/or antibiotics include the perception that aerosolized medications are not as dangerous as other chemicals. There was also a belief that employers do not fully appreciate the potential adverse health effects associated with exposure to these drugs and therefore do not prioritize adherence.


1 Dimich-Ward H, Wymer ML, Chan-Yeung M. Respiratory health survey of respiratory therapists. Chest 2004;126(4):1048-1053.

2 Harstad TW, Little BB, Bawdon, RE, Knoll K, Roe D, Gilstrap 3rd LC. [1990] Embryofetal effects of pentamidine isethionate administered to pregnant Sprague-Dawley rats. Am J Obstet Gynecol. 163(3):823-826.

3 OSHA. Controlling occupational exposure to hazardous drugsexternal icon

4 Lane AZ, Wright GE, Blair DC. Ototoxicity and nephrotoxicity of amikacin: an overview of phase II and phase III experience in the United States. Am J Med 1977;62(6):911-918.

5 Antoniu SA, Cojocaru I. Inhaled colistin for lower respiratory tract infections. Expert Opin Drug Deliv 2012;9(3):333-342.

6 Neu HC. Tobramycin: an overview. J Infect Dis 1976;134 (Suppl):S3-19.

7 NIOSH. Workplace solutions: Personal protective equipment for health care workers who work with hazardous drugspdf icon

8 Gardenhire DS, Ari A, Hess D, Myers TR. A guide to aerosol delivery devices for respiratory therapists, 3rd edition iconexternal icon Accessed February 17, 2015.

Other resources

NIOSH Alert on preventing occupational exposures to antineoplastic and other hazardous drugspdf icon

NIOSH. Workplace solutions: Medical surveillance for healthcare workers exposed to hazardous drugspdf icon

Survey and report

To request a copy of this survey, please email

Journal articleexternal icon

Page last reviewed: March 30, 2017