Is it appropriate to discharge patients on salbutamol (albuterol) nebulizers?

Discharge with Salbutamol Nebulizers: Guidelines and Best Practices

Patients should not be discharged on salbutamol nebulizers; instead, they should be transitioned to hand-held inhalers at least 24 hours prior to discharge from hospital. 1

Evidence-Based Recommendations

The British Thoracic Society (BTS) guidelines provide clear direction on this matter:

• Nebulized bronchodilator treatment should be changed to treatment with a hand-held inhaler and patients should be observed for 24-48 hours before discharge from hospital 1
• The guidelines specifically state to "change over to discharge medication by hand-held reliever/preventer 24 hours prior to discharge" 1

Rationale for Avoiding Nebulizer Discharge

1. Efficacy of Hand-Held Inhalers:

   • Adequate bronchodilator medication for most patients with asthma and COPD can be effectively delivered with standard doses given by hand-held inhalers 1
   • For asthma: salbutamol 200-400 μg or terbutaline 500-1000 μg up to four times daily
   • For COPD: salbutamol 200 μg or terbutaline 500 μg, or ipratropium bromide 40-80 μg up to four times daily

2. Reduced Medication Use:

   • Recent evidence shows that as-required (PRN) salbutamol results in significantly reduced medication use compared to regular nebulized therapy 2
   • A 2023 study in children demonstrated a 73% reduction in salbutamol use on day 1 and 69% on day 2 when using as-needed hand-held inhalers versus fixed-dose regimens 3

3. Fewer Side Effects:

   • Patients using PRN regimens report fewer side effects such as tremor and palpitations compared to those on regular nebulized therapy 2

When Home Nebulizers May Be Considered

In rare circumstances, home nebulizers might be appropriate, but only after:

1. Formal Assessment:

   • Every patient should be assessed fully by a respiratory physician or by another appropriate specialist with training in nebulizer supervision 1
   • Assessment should include review of diagnosis, peak flow monitoring, and sequential testing of different regimens 1

2. Specific Patient Populations:

   • Patients with "brittle" asthma who need to self-treat sudden attacks (uncommon cases)
   • Patients with chronic persistent asthma where hand-held inhalers at appropriate doses have failed 1
   • Palliative care situations for symptom management 1

Protocol for Transitioning to Hand-Held Inhalers

1. Select appropriate hand-held device that the patient can use efficiently
2. Assess technique and provide education on proper use
3. Transition at least 24-48 hours before discharge to ensure stability
4. Monitor response to hand-held therapy before finalizing discharge

Common Pitfalls to Avoid

• Discharging patients too quickly after transitioning from nebulizers to inhalers
• Failing to assess inhaler technique before discharge
• Not providing clear written instructions on medication use and when to seek medical attention
• Prescribing home nebulizers without formal assessment of benefit and necessity

Conclusion

Following evidence-based guidelines, patients should be transitioned from nebulized therapy to hand-held inhalers before discharge. This approach ensures adequate medication delivery while reducing unnecessary medication use, minimizing side effects, and promoting appropriate self-management.