What is the recommended treatment regimen for patients using vaporisers, such as nebulisers (nebulized inhalation therapy), for severe respiratory conditions?

Nebuliser Treatment Regimen for Severe Respiratory Conditions

For patients with severe respiratory conditions requiring nebuliser therapy, treatment should consist of nebulised bronchodilators (salbutamol 2.5-5 mg or terbutaline 5-10 mg with or without ipratropium bromide 250-500 µg) administered every 4-6 hours, but only after formal assessment demonstrates >15% peak flow improvement over standard hand-held inhaler therapy. 1

Initial Assessment Before Prescribing Nebulisers

Before initiating home nebuliser therapy, every patient must undergo formal evaluation by a respiratory physician or appropriately trained specialist 1:

• Select an efficient hand-held inhaler first and formally assess the patient's subjective and peak flow response to standard bronchodilator doses 1
• Trial higher doses via hand-held devices (e.g., 1 mg terbutaline or 400 µg salbutamol with 160 µg ipratropium four times daily) before considering nebulisers, as many patients respond well and avoid needing nebuliser trials 1
• Assess steroid responsiveness with oral or high-dose inhaled steroids for at least two weeks if not previously done 1

Peak Flow Monitoring Protocol

Patients must record peak expiratory flow (PEF) to objectively determine nebuliser benefit 1:

• Record best of three PEF readings twice daily (morning and evening, before treatment) for minimum one week on each treatment regimen 1
• Calculate average peak flow from at least five days of recordings 1
• Define treatment response as >15% increase over baseline PEF (baseline = average of two weeks on standard inhaler therapy) 1

Critical pitfall: Hospital "reversibility" tests cannot usefully predict which patients should receive long-term nebulised therapy 1

Nebuliser Drug Regimens

For Acute Severe Asthma

Initial treatment 1:

• Nebulised β-agonist: salbutamol 5 mg or terbutaline 10 mg 1
• Add ipratropium bromide 500 µg if poor response to initial β-agonist 1
• Repeat every 4-6 hours until PEF >75% predicted and diurnal variability <25% 1

For Acute COPD Exacerbations

Mild exacerbations: Hand-held inhaler with salbutamol 200-400 µg or terbutaline 500-1000 µg 1

Moderate-severe exacerbations 1:

• Nebulised salbutamol 2.5-5 mg or terbutaline 5-10 mg, OR ipratropium 500 µg every 4-6 hours for 24-48 hours 1
• Combined therapy (2.5-10 mg β-agonist with 250-500 µg ipratropium) for severe cases or poor response to monotherapy 1, 2

Critical safety consideration: If patient has CO₂ retention and acidosis, drive nebuliser with air, NOT oxygen, to prevent worsening hypercapnia 1, 2

For Chronic Domiciliary Use

After formal assessment confirms benefit 1:

• β-agonist alone (salbutamol 2.5-5 mg or terbutaline 5-10 mg four times daily), OR 1
• Ipratropium alone (250-500 µg four times daily), OR 1
• Combined β-agonist with ipratropium (doses as above) 1, 2
• Use as needed, up to four times daily (most patients choose four times daily in practice) 1, 2

Continuation Criteria

Continue domiciliary nebuliser treatment only if 1:

• Clear subjective AND peak flow response (>15% improvement) 1
• If subjective response with <15% PEF improvement, use clinical judgment 1
• Do not continue if no subjective or objective response 1

Special Populations: Elderly Patients (>65 years)

Medication considerations 1:

• Prefer anticholinergics as β-agonist response declines more rapidly with age 1
• Use caution with high-dose β-agonists in ischemic heart disease; first dose may require ECG monitoring 1
• Avoid high β-agonist doses when possible due to increased tremor risk 1

Device considerations 1:

• Use mouthpiece rather than face mask when administering high-dose anticholinergics to reduce glaucoma risk 1, 2, 3
• Consider alternative devices (spacer with face mask, breath-activated inhaler, dry powder inhaler) before nebuliser for patients unable to use metered-dose inhalers 1

Practical Administration Details

Nebulisation technique 1:

• Fill nebuliser to minimum 4.0 mL 1
• Nebulise until one minute after "spluttering" occurs (5-10 minutes total), not until "dryness" 1
• Tap nebuliser cup toward end of treatment 1
• First dose must be given under supervision with formal instruction 1

Drug mixing 3:

• Ipratropium can be mixed with albuterol or metaproterenol if used within one hour 3
• Do not mix with other drugs as stability/safety not established 3

Maintenance 1:

• Replace disposable components (tubing, cup, mask/mouthpiece) every 3-4 months 1
• Service compressors annually 1

Transition to Hand-Held Inhalers

Change to hand-held devices 1:

• When PEF >75% predicted with diurnal variability <25% 1
• Observe for 24-48 hours on hand-held inhalers before hospital discharge 1
• Switch 24 hours prior to discharge for acute asthma 1

Follow-Up Requirements

• Regular review at respiratory clinic for all patients on domiciliary nebulisers 1
• Monitor for continued benefit and proper technique 1