What are the recommendations for nebulizer (nebulized inhalation therapy) use in pediatric patients?

From the Guidelines

Nebulizers are recommended for pediatric patients who cannot effectively use metered-dose inhalers, particularly those under 4 years of age or during acute respiratory distress. For acute asthma exacerbations, albuterol (salbutamol) is the first-line medication, typically dosed at 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for three doses, then as needed 1. For maintenance therapy in asthma, inhaled corticosteroids are the preferred long-term control medication, with budesonide suspension being a common option 1. In cystic fibrosis, medications like dornase alfa or hypertonic saline may be prescribed. Proper technique is essential: the child should be seated upright, use a well-fitting mask for younger children or mouthpiece for older ones, and breathe normally during the 5-10 minute treatment. Parents should clean the nebulizer parts after each use with warm soapy water and air dry to prevent infection 1.

Some key points to consider when using nebulizers in pediatric patients include:

• The use of a face mask for children under 4 years old or a mouthpiece for older children 1
• The importance of proper cleaning and maintenance of the nebulizer to prevent infection 1
• The need for close monitoring of the child's response to therapy and adjustment of the treatment plan as needed 1
• The consideration of alternative therapies, such as metered-dose inhalers with spacers, for children who can effectively use them 1

Overall, nebulizers can be an effective and safe way to deliver respiratory medications to pediatric patients, particularly those who cannot use metered-dose inhalers. However, it is essential to follow proper technique and maintenance procedures to ensure the best possible outcomes.

From the FDA Drug Label

The safety and effectiveness of albuterol sulfate inhalation solution have been established in children 2 years of age or older Use of albuterol sulfate inhalation solution in these age groups is supported by evidence from adequate and well-controlled studies of albuterol sulfate inhalation solution in adults; the likelihood that the disease course, pathophysiology, and the drug's effect in pediatric and adult patients are substantially similar; and published reports of trials in pediatric patients 3 years of age or older The recommended dose for the pediatric population is based upon three published dose comparison studies of efficacy and safety in children 5 to 17 years, and on the safety profile in both adults and pediatric patients at doses equal to or higher than the recommended doses The safety and effectiveness of albuterol sulfate inhalation solution in children below 2 years of age have not been established. Patients should be advised that mydriasis, temporary blurring of vision, precipitation or worsening of narrow-angle glaucoma or eye pain may result if the solution comes into direct contact with the eyes Use of a nebulizer with a mouthpiece rather than a face mask may be preferable, to reduce the likelihood of the nebulizer solution reaching the eyes.

The recommended nebulizer use in pediatric patients is to use a mouthpiece rather than a face mask to reduce the likelihood of the nebulizer solution reaching the eyes.

• The safety and effectiveness of albuterol sulfate inhalation solution have been established in children 2 years of age or older.
• The recommended dose for the pediatric population is based upon three published dose comparison studies of efficacy and safety in children 5 to 17 years.
• Caution should be exercised when using nebulizers in pediatric patients, especially in those under 2 years of age, as the safety and effectiveness of albuterol sulfate inhalation solution have not been established in this age group 2.
• Pediatric use of ipratropium bromide inhalation solution has not been established for patients under 12 years of age 3.

From the Research

Nebulizer Recommendations in Pediatric Patients

• The use of nebulized albuterol in pediatric patients with acute asthma has been studied in various trials 4, 5, 6.
• A study from 1990 found that high-dose hourly albuterol therapy (0.30 mg/kg body weight) resulted in significantly greater improvement in forced expiratory volume in 1 second (FEV1) compared to standard-dose therapy (0.15 mg/kg) in children with moderate to severe acute asthma 4.
• Another study from 2020 compared two continuous nebulized albuterol doses (10 vs. 25 mg/h) in critically ill children with status asthmaticus and found that the lower dose was associated with lower fluid bolus resuscitation without increased adjunctive therapies 5.
• The addition of ipratropium bromide to nebulized albuterol has been studied, but one trial from 2001 found no significant differences in hospital length of stay, asthma carepath progression, or adverse effects between the treatment groups 7.
• High-dose albuterol by metered-dose inhaler plus a spacer device has been shown to be equivalent to nebulization in preschool children with recurrent wheezing 8.
• A rapid albuterol pathway with a breath-enhanced nebulizer has been compared to a standard pathway for the treatment of children with moderate to severe asthma exacerbation in the emergency department, and was found to reduce emergency department length of stay 6.

Dosage and Administration

• The optimal dosage of nebulized albuterol in pediatric patients is not well established, but studies have used doses ranging from 0.15 mg/kg to 0.30 mg/kg body weight 4, 5.
• Continuous nebulized albuterol doses of 10 mg/h and 25 mg/h have been compared in critically ill children with status asthmaticus, with the lower dose being associated with fewer side effects 5.
• The use of a spacer device with a metered-dose inhaler has been shown to be an effective alternative to nebulization in preschool children with recurrent wheezing, with a dose of 50 microg/kg being used 8.

Special Considerations

• Pediatric patients with acute asthma may require repeated doses of nebulized albuterol, and the use of a breath-enhanced nebulizer may help to reduce emergency department length of stay 6.
• The addition of ipratropium bromide to nebulized albuterol may not provide significant benefits in terms of hospital length of stay or asthma carepath progression, but may be considered in certain cases 7.