Nebulisation for Breathlessness in Pneumonia
Nebulisation is NOT routinely recommended for breathlessness in uncomplicated pneumonia, as the primary treatment is antimicrobial therapy and supplemental oxygen; however, nebulised bronchodilators should be used if there is concurrent reversible airflow obstruction (wheezing, bronchospasm) or underlying COPD/asthma. 1, 2
When Nebulisation IS Indicated in Pneumonia
Concurrent Bronchospasm or Airflow Obstruction
- Nebulised bronchodilators (salbutamol 2.5-5 mg or ipratropium bromide 250-500 μg) are indicated when pneumonia coexists with reversible airflow obstruction, acute asthma exacerbation, or COPD exacerbation. 2
- The British Thoracic Society specifies that nebulisers are preferable when controlled coordinated breathing is difficult in sick patients, making them appropriate for severely breathless pneumonia patients with bronchospasm. 1
- For mechanically ventilated pneumonia patients with acute airflow obstruction, nebulised β-agonists and ipratropium bromide improve lung function and should be used in combination with systemic steroids, antibiotics, and intravenous bronchodilators. 1
Driving Gas Selection (Critical Safety Point)
- Use compressed air (NOT oxygen) as the driving gas at 6-8 L/min for nebulisation in pneumonia patients, unless the patient has acute severe asthma. 1, 2
- Oxygen should only drive nebulisers in acute severe asthma because these patients are hypoxic and require simultaneous treatment of both bronchospasm and hypoxemia. 2
- In COPD patients with pneumonia, oxygen-driven nebulisers risk worsening carbon dioxide retention and acidosis. 2
- If supplemental oxygen is needed during air-driven nebulisation, administer low-flow oxygen (≤4 L/min) via nasal cannulae simultaneously. 2
When Nebulisation is NOT Indicated
Standard Pneumonia Without Bronchospasm
- Breathlessness from pneumonia itself (due to consolidation, hypoxemia, or increased work of breathing) does not respond to nebulised medications. 1
- The primary treatment remains appropriate antimicrobials and oxygen supplementation via standard delivery methods (nasal cannula, simple mask, or Venturi mask). 3
- Non-invasive ventilation or high-flow nasal therapy may be more appropriate than nebulisation for severe hypoxemic respiratory failure in pneumonia. 4, 3
Nebulised Antibiotics
- Nebulised antibiotics are NOT recommended for routine treatment of community-acquired pneumonia. 5, 6
- While nebulised antibiotics may increase microbiological eradication rates in mechanically ventilated patients with multidrug-resistant pneumonia, they increase the risk of bronchospasm (OR 3.15) and do not improve clinical recovery or survival. 6
- The evidence quality is low with high risk of publication bias, and this approach is restricted to specific ICU populations with resistant pathogens. 6
Palliative Care Context
End-Stage Disease
- In palliative care settings with advanced pneumonia, nebulised bronchodilators may be used for breathlessness palliation only if concurrent reversible airflow obstruction is present. 1
- Nebulised local anaesthetics (lignocaine 2-5 ml) should NOT be used for palliation of breathlessness despite being indicated for non-productive cough. 1
- Normal saline nebulisation (5 ml six hourly) may be tried to loosen tenacious secretions, though scientific evidence is lacking. 1
Critical Pitfalls to Avoid
- Never use oxygen to drive nebulisers in COPD patients with pneumonia - this can precipitate life-threatening hypercapnic respiratory failure. 1, 2
- Do not confuse breathlessness from pneumonia (which requires oxygen and antimicrobials) with breathlessness from bronchospasm (which requires bronchodilators). 1
- Avoid using nebulised water, as it may cause bronchoconstriction when nebulised; use 0.9% sodium chloride instead. 1
- In elderly patients with ischemic heart disease and pneumonia, use high-dose β-agonist nebulisers with caution due to increased risk of cardiac complications and tremor. 1, 7