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Nasal irrigation

Do CF patients still have to use sterile salt water for nasal irrigation? After all, if we boil water for this, it has to cool down for at least 20 minutes; but during this time germs will form again!?!

As with all therapies of the respiratory system in CF patients, avoiding the transmission of germs is of utmost importance. The nose, with its paranasal sinuses, constitutes a filtering system that is defective in CF and thus facilitates colonization with problematic germs such as Pseudomonas aeruginosa. Water and inhalation or lavage systems in which diluted solutions are administered generally bear the risk of being germ reservoirs. Therefore, a lot of effort is put into the cleaning and drying of inhalation devices, and the same is also necessary for nasal irrigation systems. If these aspects are not followed, the therapeutic effort can become harmful in individual cases. Considering this background, I have recommended up to now the consistent use of freshly boiled water cooled down to body temperature, with sodium chloride added until a ca. 0.9% solution is obtained, and with or without traces of other salts for nasal irrigation. The boiling kills bacteria, which is why it is suitable for sterilisation. Afterwards, germs will have to first get into the vessel, so that there is no relevant germ reproduction to be expected for several hours.

I have noticed in many conversations that a lot of people use water directly from the tap for nasal irrigation due to the effort involved in boiling it and cooling it down. Without disorders of the respiratory system’s cleansing mechanism, such as in CF, and without immunodeficiency (which people with CF usually do not have), using tap water – after flushing out the first portion from the pipes, and without swirling up water from the siphon – is relatively harmless. With CF, nasal irrigation should be avoided without first cleaning the pot adequately and without following the last two measures mentioned. Boiling the water will offer maximum safety.

Kind regards
Dr. Jochen Mainz


[Dr. Mainz asked microbiologist Dr. Michael Hogardt for his views on the issue; here is Dr. Hogardt’s amendment to Dr. Mainz’s answer:]

"A sterile solution should be used for rinsing. Using boiled water is practicable, since all CF-relevant ‘humid germs’ can easily be killed this way. 20 minutes are easily sufficient for the relevant bacteria. Secondary contamination and recurring microbial contamination is thinkable. Contamination, relevant secondary contamination and reproduction are hardly conceivable during the cooling-down, though. I would nevertheless recommend swift usage of the boiled water. For killing the germs, just a few minutes at boiling temperature would probably be enough. The 20-minute recommendation provides a comfortable safety margin, as correct execution is a prerequisite. I would strictly advise against using tap water, even if the germ count is reduced by the ‘flushing’. The microbial contamination of water-conducting systems can vary widely; it is therefore impossible to make a general statement here.

Kind regards
Michael Hogardt"