From the Guidelines
For patients with advanced dementia and COPD who can no longer use Advair inhalers, nebulized salbutamol (2.5–5 mg) or terbutaline (5–10 mg) combined with ipratropium bromide (500 µg) is the best alternative, as it provides effective bronchodilation and is a cost-effective option. According to the British Thoracic Society Nebulizer Project Group 1, in more severe cases of COPD, nebulised salbutamol or terbutaline or ipratropium bromide should be given 4–6 hourly for 24–48 hours or until the patient is improving clinically. Some key points to consider when using nebulizer medications for advanced dementia patients with COPD include:
- Nebulized bronchodilator treatment should be adjusted based on the patient's response and clinical improvement
- Combined nebulised treatment with a β agonist and ipratropium bromide should be considered in more severe cases
- The nebuliser should be driven by air (not high flow oxygen) if the patient has carbon dioxide retention and acidosis
- Proper nebulizer cleaning after each use is essential to prevent infection
- A caregiver should be present to assist the patient during nebulizer treatments and ensure the mask is properly placed over the patient's face. Nebulized medications can be administered 3-4 times daily, and the treatment should be monitored and adjusted as needed to ensure the patient's symptoms are well-controlled.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Nebulizer Medication Alternatives for Advanced Stage Dementia and COPD Patients
- For patients with advanced stage dementia and chronic obstructive pulmonary disease (COPD) who can no longer use their Advair (fluticasone-salmeterol) inhaler, nebulized therapy can provide an alternative administration route that avoids the need for inspiratory flow, manual dexterity, or complex hand-breath coordination 2.
- The recent approval of nebulized long-acting muscarinic antagonists has added to the range of nebulized therapies available for COPD patients, providing benefits similar to drugs delivered by handheld inhalers in both symptom relief and improved quality of life 3, 2.
Cost-Effective Options
- Nebulizers can be a costly option, but they may be necessary for patients who are unable to use handheld inhalers due to cognitive or physical impairments 4.
- The combination of ipratropium bromide and albuterol has been shown to be effective in optimizing pulmonary function reversibility testing in patients with COPD, and may be a cost-effective alternative to other nebulized therapies 5.
- A short-term comparison of fluticasone propionate/salmeterol with ipratropium bromide/albuterol found that both combination therapies improved lung function, symptoms, and supplemental albuterol use, but fluticasone propionate/salmeterol was more effective in improving morning pre-dose FEV(1) and other outcomes 6.
Considerations for Patient Populations
- Patients with cognitive, neuromuscular, or ventilatory impairments may have challenges with handheld inhalers and may benefit from nebulized therapy 2.
- The use of spacers and valved holding chambers with pressurized metered-dose inhalers (pMDIs) can increase the efficiency of aerosol delivery, but may not be suitable for all patients 2.
- Nebulized therapy can provide a useful treatment option for certain patient populations with COPD, particularly those who are unable to use handheld inhalers due to cognitive or physical impairments 3, 2.