What steroid can be used in a nebulizer for a patient in respiratory distress?

Nebulized Steroids for Respiratory Distress

Recommended Steroid for Nebulization

Budesonide is the recommended steroid for nebulization in patients with respiratory distress, typically administered at a dose of 500 μg. 1

• Budesonide is specifically formulated as a suspension for nebulization (available as Pulmicort respules) and is the only steroid with established evidence for nebulized delivery in respiratory conditions 2
• Budesonide suspension should be administered using a jet nebulizer rather than an ultrasonic nebulizer, as ultrasonic nebulizers have been proven inefficient in nebulizing suspensions 3
• A mouthpiece should be used rather than a face mask when administering nebulized budesonide to prevent facial deposition of the medication 4

Administration Guidelines

• For respiratory distress in adults, budesonide can be nebulized at doses of 1-4 mg twice daily, with higher doses providing potentially better outcomes in more severe cases 5
• For children with croup (a form of respiratory distress), 500 μg of nebulized budesonide has been shown to reduce symptoms in the first two hours 1
• Budesonide should be administered from jet nebulizers at adequate flow rates (6-8 L/min) to achieve optimal particle sizes of 2-5 μm for proper deposition in the small airways 1, 6
• Oxygen should be used as the driving gas for nebulization in acute severe respiratory distress whenever possible, as patients are likely to be hypoxic 1

Clinical Considerations

• Patients should rinse their mouth after using nebulized budesonide to prevent oral thrush 4
• In severe respiratory distress, nebulized budesonide can be used alongside systemic corticosteroids (such as prednisone or dexamethasone) for more comprehensive anti-inflammatory coverage 4, 7
• Nebulized budesonide has a favorable therapeutic ratio and good tolerability profile, making it suitable for both initial treatment and maintenance therapy 8
• Regular preventative treatments should be continued even when using nebulizer therapy 1

Common Pitfalls and Caveats

• Water should never be used for nebulization as it may cause bronchoconstriction when nebulized 1
• The conventional ultrasonic nebulizer is inefficient in nebulizing budesonide suspension; a jet nebulizer should be used instead 3
• If a nebulizer breaks down, patients should use their hand-held inhaler until they can get help 1
• Nebulized steroids should only be used on a doctor's recommendation and are not a first-line treatment for all forms of respiratory distress 1
• In some cases, a metered-dose inhaler with a spacer may be as effective and cheaper than nebulization, particularly for children 1

Special Populations

• For patients with hepatic impairment, close monitoring is recommended as budesonide is predominantly cleared by hepatic metabolism 2
• In geriatric patients, no overall differences in safety have been observed compared to younger patients 2