From the Guidelines
Bromhexine hydrochloride is the most effective nebulizer medication for helping with expectoration of phlegm, as it increases the production of serous mucus, making the sputum thinner and less viscous, and improves difficulty in expectoration. This is based on a study published in 2019 1, which found that bromhexine hydrochloride was effective in increasing sputum production and improving difficulty in expectoration in patients with bronchiectasis. The study found that the percentage change in sputum production was greater in the bromhexine group at 7,10, and 16 days, and that the difficulty in expectoration was also improved in the bromhexine group at day 10.
Some key points to consider when using bromhexine hydrochloride include:
- It is thought to influence sputum clearance by increasing the production of serous mucus, thereby making the sputum thinner and less viscous
- It has been shown to be effective in improving sputum production and difficulty in expectoration in patients with bronchiectasis
- It is not widely available in the UK and is not listed in the BNF, which may limit its use in some clinical settings
Other medications, such as dornase alfa (Pulmozyme) and erdosteine, have also been studied for their effectiveness in helping with expectoration of phlegm. However, the evidence for these medications is not as strong as it is for bromhexine hydrochloride. Dornase alfa has been shown to break down DNA in mucus, making it less viscid and easier to expectorate, but it has also been associated with an increased risk of exacerbations in patients with bronchiectasis 1. Erdosteine has been shown to modulate mucus production through the scavenging activity of free radicals, but the evidence for its effectiveness is limited and of poor methodological quality 1.
In terms of nebulizer technique, it is recommended to use proper technique, such as sitting upright, taking slow deep breaths, and following with airway clearance techniques like controlled coughing or chest physiotherapy, to maximize phlegm removal. Adequate hydration also helps thin secretions naturally to complement these treatments. Bronchodilators like albuterol (2.5 mg per treatment) may be used before mucolytics to open airways and improve medication delivery, as recommended in the European Respiratory Society guidelines on the use of nebulizers 1.
From the FDA Drug Label
Acetylcysteine solution is available in rubber stoppered glass vials containing 30 mL. The 20% solution may be diluted to a lesser concentration with either Sodium Chloride Injection, Sodium Chloride Inhalation Solution, Sterile Water for Injection, or Sterile Water for Inhalation Acetylcysteine solution does not contain an antimicrobial agent, and care must be taken to minimize contamination of the sterile solution.
Acetylcysteine is a nebulizer medication that helps with expectoration of phlegm (mucus) 2.
- It is administered via nebulization into a face mask, mouth piece, or tracheostomy.
- The recommended dose for most patients is 3 to 5 mL of the solution 3 to 4 times a day.
- Acetylcysteine solution may be introduced directly into a particular segment of the bronchopulmonary tree by inserting a small plastic catheter into the trachea.
- It is used for the routine nursing care of patients with tracheostomy.
From the Research
Nebulizer Medications for Expectoration of Phlegm (Mucus)
- Hypertonic saline is a nebulizer medication that has been studied for its effectiveness in helping with expectoration of phlegm (mucus) 3, 4, 5, 6.
- The use of hypertonic saline has been shown to improve mucociliary clearance and lung function in patients with cystic fibrosis and chronic obstructive pulmonary disease (COPD) 3, 5.
- In patients with acute bronchiolitis, nebulized hypertonic saline (3%) has been found to be as effective as normal saline (0.9%) and salbutamol nebulization in reducing the duration of oxygen therapy and hospital stay 4.
- A Cochrane review of 34 trials found that nebulised hypertonic saline may reduce the length of hospital stay and improve clinical severity scores in infants with acute bronchiolitis, and may also reduce the risk of hospitalisation amongst outpatients and ED patients 6.
- Other nebulizer medications that may help with expectoration of phlegm include acetylcysteine and salbutamol, which have been studied in the context of preventive nebulization in invasively ventilated intensive care unit patients 7.
Mechanism of Action
- Hypertonic saline works by increasing the volume of airway surface liquid, which helps to restore mucus clearance and improve lung function 5.
- The use of hypertonic saline has been shown to produce a sustained acceleration of mucus clearance and improve lung function in patients with cystic fibrosis 5.