What conditions are treated with nebulized (NEB) therapy?

What Nebulizer Treatments Help With

Nebulizer therapy is primarily used to deliver bronchodilators for acute and chronic airway obstruction in asthma and COPD, as well as antibiotics for cystic fibrosis, corticosteroids for severe respiratory conditions, and mucolytics for secretion management. 1

Primary Respiratory Conditions

Asthma

• Acute severe asthma requires nebulized beta-agonists (salbutamol 5 mg or terbutaline 10 mg) combined with ipratropium bromide 500 μg, repeated every 4-6 hours until peak flow exceeds 75% of predicted normal 1
• Chronic asthma may benefit from nebulized therapy when patients demonstrate at least 15% improvement in mean baseline peak flow over standard inhaler therapy 1
• Brittle asthma with sudden severe attacks requires high-dose beta-agonist nebulization (salbutamol 5 mg or terbutaline 10 mg) 1

Chronic Obstructive Pulmonary Disease (COPD)

• Acute COPD exacerbations should be treated with nebulized salbutamol (2.5-5 mg) or terbutaline (5-10 mg) or ipratropium bromide (500 μg) given 4-6 hourly for 24-48 hours 1
• Combined nebulized treatment (2.5-10 mg beta-agonist with 250-500 μg ipratropium bromide) is recommended for severe cases with poor response to single-agent therapy 1
• Chronic severe COPD may require long-term domiciliary nebulizer therapy after formal assessment by a respiratory physician demonstrates objective benefit 1

Specialized Therapeutic Applications

Cystic Fibrosis

• Nebulized antibiotics (colistin and gentamicin) are indicated for selected patients with cystic fibrosis, requiring mouthpiece administration with filters to prevent environmental contamination 1, 2
• Nebulized rhDNase has demonstrated benefit in selected patients during medium-term treatment 1

Pediatric Conditions

• Croup responds to nebulized corticosteroids (budesonide 500 μg), which reduces symptoms within the first two hours and is equally effective as oral dexamethasone 1, 3
• Pediatric asthma can be treated with nebulizers, though hand-held inhalers with spacers are equally effective in most situations 1
• Bronchiolitis does not benefit from nebulized beta-agonists, ribavirin, or corticosteroids and these treatments should not be used 1

Other Indications

• Pneumocystis carinii pneumonia in HIV-positive patients is treated or prevented with nebulized pentamidine, requiring mouthpiece administration 2
• Sputum induction uses hypertonic saline (3%) with high-output nebulizers, requiring oxygen saturation monitoring due to desaturation risk 4

Medication Categories Delivered by Nebulizer

Bronchodilators

• Beta-agonists (albuterol/salbutamol) are the most commonly nebulized medications for acute and chronic airway obstruction, with recommended volumes of 2.0-4.5 mL 2
• Anticholinergics (ipratropium bromide) are frequently used at doses of 250-500 μg, particularly in COPD and when combined with beta-agonists 1, 2

Corticosteroids

• Budesonide is the recommended nebulized steroid, typically administered at 500 μg doses, with patients instructed to rinse their mouth afterward to prevent oral thrush 2, 3
• Mouthpiece administration is preferred over masks to prevent facial deposition and reduce thrush risk 2

Mucolytics and Saline

• Normal saline (0.9% sodium chloride) is used to assist physiotherapy and facilitate mucus clearance, administered in 2-5 mL volumes 4
• Acetylcysteine (Mucomist) requires specially chosen equipment due to its viscosity and may take longer than standard 10-minute nebulization 2

Critical Safety Considerations

Gas Selection

• Oxygen should drive nebulization in acute severe asthma due to hypoxia risk 4, 3
• Air should drive nebulization in COPD patients unless oxygen is specifically prescribed, as carbon dioxide retention may occur 1, 4

Equipment Maintenance

• Daily cleaning is mandatory for regularly used nebulizers: disassemble, wash in warm water with detergent, rinse, and dry thoroughly 2, 4
• Disposable components (tubing, nebulizer cup, mask/mouthpiece) require replacement every 3-4 months 4
• Compressors require annual servicing 4

Common Pitfalls to Avoid

• Never use water as a diluent for nebulization as it causes bronchoconstriction; only 0.9% sodium chloride is acceptable 4, 3
• Glaucoma exacerbation can occur with anticholinergics when using masks; mouthpieces should be used instead 2
• Cross-contamination risk exists if equipment is not properly cleaned 2
• Not every patient benefits from high-dose nebulized therapy; objective improvement (≥15% peak flow increase) must be demonstrated before long-term prescription 1

Administration Technique

• Patients should sit upright, take normal steady breaths with occasional deeper breaths, and keep the nebulizer upright during treatment 2
• Gas flow rate of 6-8 L/min is recommended to generate optimal particle sizes of 2-5 μm for small airway deposition 4
• Treatment duration is typically 10 minutes for bronchodilators, continuing until about one minute after "spluttering" occurs 4
• First dose supervision is mandatory, with formal instruction on nebulizer use before home therapy 2