What medications can be mixed with a nebulizer solution for inhalation via mask?

Medications That Can Be Mixed with Nebulizer Solutions in a Mask

Bronchodilators such as β-agonists (salbutamol/albuterol, terbutaline) and anticholinergics (ipratropium bromide) can be safely mixed together in a nebulizer mask for improved efficacy in respiratory conditions. 1

Compatible Medications for Nebulizer Mixing

Bronchodilator Combinations

• β-agonists (salbutamol/albuterol or terbutaline) can be mixed with ipratropium bromide, with the combined solution typically made up to 4.5 ml total volume 1
• This combination is particularly beneficial in acute asthma and COPD exacerbations, providing better bronchodilation than either therapy alone 2, 3
• The FDA label for ipratropium bromide specifically states it can be mixed with albuterol or metaproterenol if used within one hour 4

Corticosteroids

• Budesonide can be mixed with bronchodilators (albuterol and ipratropium bromide) while maintaining satisfactory drug output and respirable particle size 5
• When mixing steroids with other medications, a mouthpiece is generally preferred over a mask to prevent facial deposition, but masks can be used when necessary 1, 6

Other Compatible Medications

• Antibiotics (e.g., colistin and gentamicin) can be nebulized for conditions like cystic fibrosis 1
• Lignocaine (lidocaine) can be nebulized for cough relief in terminal care 1
• 0.9% sodium chloride (normal saline) can be used to assist with physiotherapy and can be mixed with other medications 1

Administration Guidelines

Volume and Flow Rate Considerations

• The optimal volume of fluid in the nebulizer chamber is usually 2.0-4.5 ml 1
• A gas flow rate of 6-8 L/min should be used to nebulize particles to 2-5 μm diameter for optimal deposition in small airways 1
• Increasing fill volume (from 3 to 5 ml) decreases the amount of medication trapped in dead volume and increases the amount delivered to the patient 7

Mask vs. Mouthpiece Selection

• Masks are better for:
  • Acutely ill patients when holding the nebulizer is tiring 1
  • Babies and young children when coordination is difficult 1
• Mouthpieces should be used for:
  • Nebulized steroids to prevent deposition on the face 1
  • Nebulized antibiotics so a filter can be used to prevent exhalation of antibiotic into the air 1
  • Sometimes for anticholinergics as they may exacerbate glaucoma 1

Important Precautions

Stability and Compatibility

• Water should never be used as a diluent as it may cause bronchoconstriction when nebulized 1, 8
• Drug stability of ipratropium bromide when mixed with medications other than albuterol or metaproterenol has not been established 4
• Solutions containing albuterol free base (rather than albuterol sulfate) can show significant degradation within 5 hours when mixed with other medications 9

Technique and Cleaning

• Patients should rinse their mouth after nebulizing steroids and antibiotics to prevent oral thrush 1, 8
• Each patient should have their own tubing, nebulizer, and mouthpiece/mask, even if they share a compressor 1
• Nebulizers should be cleaned after each use to avoid crystallization and growth of microorganisms in residual fluid 1

Special Considerations for Specific Conditions

Asthma

• In acute severe asthma, oxygen should be used as the driving gas for nebulization when possible, as patients are likely to be hypoxic 1
• A mixture of salbutamol and ipratropium bromide provides better peak flow response than nebulized salbutamol alone in acute asthma 2

COPD

• Oxygen should not be routinely used for nebulizers in patients with COPD due to risk of carbon dioxide retention 1
• For COPD patients, maintenance therapy with combined ipratropium bromide and albuterol provides better bronchodilation than either therapy alone 3