Nebuliser Guidance and Monographs - Adult

Publication: 01/04/2011  
Next review: 01/08/2025  
Clinical Guideline
CURRENT 
ID: 2454 
Approved By: LTHT Drugs and Therapeutics Committee 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

The Leeds Teaching Hospitals NHS Trust Adult Nebuliser Guidance and Monographs

Introduction

How do I administer a medicine via a nebuliser?

Nebuliser Assessment Guide (Adults only)

Individual Drug Monographs

Compatibility of Nebuliser Solutions

Appendices

Introduction

Scope of Guidelines

These guidelines cover all staff working on behalf of The Leeds Teaching Hospitals NHS Trust who prescribe and administer nebulised therapy.

The purpose of these guidelines is to:

  • Provide a framework for standardised nebuliser prescribing and administration
  • Provide healthcare professionals with support, knowledge and evidence of good practice necessary for them to safely prescribe and administer nebulised therapies

Nebulised medications must be prescribed and administered in accordance with The Leeds Teaching Hospitals NHS Trust Medicines Code.

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How to use these guidelines

These guidelines have been set out in a format which makes them easy to use in a ward/clinic environment. 

The initial sections contain general information regarding appropriate patient selection for nebulisers and a pictorial glossary of all the equipment use to ensure clarification of terms throughout the guideline.  There is also a step by step guide on how to administer a medicine via a nebuliser, this may differ in specific patient populations for example in adults, Children and Cystic Fibrosis (CF).  Ensure you are familiar with this section prior to administering or prescribing any nebulised therapy.

For guidance on how to nebulise a specific drug see the individual drug monograph.   There are also links to the Summary of Product Characteristics (SPC) and Drug and Therapeutics (D&T) submission for the product, where available.  The compatibility table in this guidance indicates which drugs can be mixed prior to nebulisation.

Within the appendices there is a checklist for discharging a patient on a nebuliser, which may be printed and placed in the patient’s nursing notes. In this addition there is also guidance on assessment of nebulised therapy to support staff on the wards and clinics at LTHT.

The appendices also contain patient information leaflets. The initial patient information leaflet contains general information on the use of nebulisers, including information on servicing etc.  These leaflets will be supplied by equipment with every compressor that is issued.  However, ward staff may want to print out one of these for patients on discharge.  The other patient information leaflets are for drugs which when used within a nebuliser are unlicensed or off-label uses and therefore the patient information leaflets already contained within the drug may not be suitable. These should be given to all patients discharged on these medications.

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Why use nebulised therapy?

‘The aim of nebuliser treatment is to deliver a therapeutic dose of a drug as an aerosol in the form of respirable particles within a fairly short period of time’1

Nebulisers are most beneficial when:

  • Large inhaled drug doses are required
  • Patients are too unwell to be able to co-ordinate hand-held drug delivery devices such as inhalers; if a patient is well and unable to use a hand-held inhaler then they are unlikely to be able to use a nebuliser and thus should not be prescribed as a substitute
  • Drugs are unavailable in hand-held inhalers, e.g. antibiotics
  • Patients are unable to take deep breaths or when breath holding is not appropriate, making inhalers difficult to use

Patients should be changed to hand-held inhalers, if appropriate and available, once their condition has stabilised as it may permit earlier discharge from hospital.

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Mouthpiece or Mask?

Mouthpieces should be used as standard in all patients. 

A mask may theoretically deliver less medication to the lungs as nasal inhalation is used as opposed to mouth inhalation2.  In addition, mouthpieces limit environmental contamination and/or contact with the patient’s eyes. Masks should only be used in exceptional circumstances and should be tight fitting.  Patients should be advised to breathe with an open mouth1.

Tracheostomy patients who are self-ventilating on air, should have the nebuliser attached to a tracheostomy mask.  However if they are currently being ventilated, the nebuliser should be attached to a T-piece or delivery device suitable for use with the type of ventilator in use, which is inserted into the ventilator circuit.

Mouthpiece and mask packs (that include tubing and nebuliser chamber) can be ordered from supplies.

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Initiating domiciliary nebulised therapy in patients with Chronic Obstructive Pulmonary Disease (COPD)

Patients with distressing or disabling breathlessness despite maximal handheld therapy should be considered for domiciliary nebuliser therapy3. All patients with COPD who require initiation on nebulised therapy must receive a formal assessment. 

Note: If patients are discharged home from hospital with a nebuliser please refer to the community Respiratory Team for review. Outpatients should be referred to LCH respiratory community team (leedsintegrated.copdservice@nhs.net) and NOT the Cardio-Respiratory Team.

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Domiciliary Nebulised Therapy - Filters or aerosol hosing?

For nebulised therapy where filters are required within the hospital, e.g. antibiotics, aerosol hosing is usually used at home but for some patients filters may be required. For example, a filter may be needed where a suitable room at home is not available, or where they may be a risk of exposure to other residents. Further supplies can be obtained from the respiratory nurse specialists and equipment pool.

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Equipment Glossary -

  • Compressor - a machine that takes in room air and expels it at high pressures. There are several types of compressors available:

AC2000/3000/4000 - blue/white compressor with white stripe and lift up lid.  Suitable for antibiotics, bronchodilators, dornase alfa, corticosteroids, sodium chloride and liposomal amphotericin

Portaneb - White compressor with lift up lid. Suitable for antibiotics, bronchodilators, dornase alfa, corticosteroids, sodium chloride and liposomal amphotericin.

InnoSpire Deluxe - White/grey compressor with storage compartment. To be used in conjunction with SideStream nebulisers  Suitable for antibiotics, bronchodilators and corticosteroids
InnoSpire essence
OMBRA

 

  • Filter - there are two types of filters. One filter is within the compressor - these should be changed every 3 months. The other type of filter is used with other specific nebulisers. These are placed within the ‘filter housing’ attached to the nebuliser chamber and should be changed after each use.

 

Compressor Filter (Medix)

 

 

 

 

Compressor Filter (Portaneb)

 

Innospire Delux Filter
LC Plus Filters

SideStream Plus Filters

 

  • Mouthpiece - Mouthpiece - Plastic mouthpiece attached to nebuliser chamber. This is the delivery device of choice in all patients.

  • Mask - Should only be used in exceptional circumstances. Attach to nebuliser chamber via tubing.
    DO NOT use to administer ipratropium to patients with glaucoma.
  • If masks are required ensure they are fitted correctly and patients should be advised to breathe with an open mouth1.

 

  • Nebuliser chamber - this is attached to the compressor via tubing and is where the nebuliser liquid is placed. Combined with the compressor the liquid medication is then turned into mist, which can be inhaled. Different medications require different nebuliser chambers; please refer to the relevant individual drug monograph. The types available are for example:

SideStream

 

SideStream Plus

 

 

Par LC Plus (Not compatible with Philips Compressors) 

 

  • e-Flow - USED IN CYSTIC FIBROSIS PATIENTS ONLY. A blue portable nebuliser that enables extremely efficient delivery of medication via a vibrating, perforated membrane.

 

  • I-neb - USED IN CYSTIC FIBROSIS PATIENTS ONLY. A portable and quiet nebuliser that has a reduced nebulisation time compared to conventional nebulisers.

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Equipment Order Numbers

Item

NHS Supplies Order Number

Compressors

For domiciliary use these are available from equipment pool.  Individual wards are responsible for ordering compressors forward use.

SideStream mouthpiece tubing kit

FDE000

SideStream mouthpiece

FDE514

SideStream mask tubing kit

FDE819

Durable SideStream nebuliser chamber

FDE032

SideStream Plus with aerosol hose
(for home use only)

FDE038

SideStream Plus with Filter
(for use on wards or at home)

FDE039

Replacement Filters (pack of 50) for SideStream Plus

FTC155

Pari LC Plus

FDE265

Pari LC Plus filters

FDE199

 

eFlow

Cystic fibrosis patients only - discuss with cystic fibrosis physiotherapists

I-neb

NB. Continuing supplies for patients can be ordered by the patient direct from LTHT Equipment Pool – see patient information leaflet - Appendix 2

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How do I administer a medicine via a nebuliser?

  1. Nebulisers are for single patient use: label with the patient’s addressograph sticker and the date and time of first use. In hospital the nebuliser pot should be changed every 24 hours.  NB. Nebuliser pots in cystic fibrosis patients may be used for longer than 24 hours due to different cleaning practices.
  2. Hands should be decontaminated before any patient contact - please follow the Leeds Teaching Hospitals NHS Trust (LTHT) Hand Hygiene Policy (available on Infection Control website on LTHT Intranet).
  3. Sit patient up in bed or chair, well supported by pillows and make him/her comfortable to ensure the best possible chest expansion is achieved.
  4. Explain the procedure to the patient and obtain verbal consent.  Listen to and answer the patient’s questions to alleviate any anxiety.
  5. Ensure that the equipment is clean and dry. Place the appropriate nebuliser solution into the nebuliser chamber.  A final volume of at least 2mL to 4mL is recommended.  Add sodium chloride 0.9% if dilution is required.  Water should not be used as it can cause bronchospasm4. Please consult manufacturers advice for maximal fill volume for each device.

    NB.  For specific drug advice please see the individual drug monographs within this guideline.
  6. Connect nebuliser tubing to a compressor, or oxygen if prescribed.  If piped oxygen is used, it should be set at a flow rate of 6-8 litres/min.

    Please note that patients with chronic obstruction pulmonary disease (COPD) should receive nebulisers driven by a compressor not oxygen.  This is to avoid CO2 retention and subsequent type 2 respiratory failure5.    If these patients also require oxygen, it should be administered using nasal cannula whilst the nebuliser is being used.

    Patients receiving nebulised bronchodilators for exacerbations of asthma should receive these using oxygen as the driving gas6.
  7. Set the flow rate depending on the drug/compressor/nebuliser requirements - see individual drug monographs.  The correct flow rate is needed to create particles of the optimum size to penetrate the distal airways7.
  8. Ensure mouthpiece is attached to nebuliser.  Mouthpieces should be used in the majority of patients; exceptions are unconscious patients, patients with a tracheostomy or small children.  Masks should only be used in exceptional circumstances and should never be used when nebulising ipratropium to patients with glaucoma.

    Tracheostomy patients who are self-ventilating on air, should have the nebuliser attached to a tracheostomy mask.  However if they are currently being ventilated, the nebuliser should be attached to a T-piece or appropriate device depending on the ventilator in use, which is inserted into the ventilator circuit.
  9. Filters should be used for patients in hospital who are being administered an antibiotic7.  These filters are single use only.
  10. Switch on nebuliser compressor or oxygen supply.  The patient should place mouth around mouthpiece ensuring a tight seal and breathe as normal.  Leave until it stops producing mist.  This should be less than 5 minutes with a fill volume of 2mLs.  It may be up to 10 minutes for larger fill volumes7.
  11. The nebuliser chamber may be tapped once or twice towards the end of treatment to release any droplets trapped in the chamber7.
  12. Any residual fluid can be an ideal medium for bacteria to grow therefore please follow the nebuliser cleaning instructions within this guideline see appendix (2).7,9
  13. Hands should be decontaminated after any patient contact - please follow the Leeds Teaching Hospitals NHS Trust (LTHT) Hand Hygiene Policy (available on Infection Control website on LTHT Intranet).

Should I use a syringe?

Where feasible medicinal products made specifically for nebulisation should be decanted into the nebuliser chamber directly.

For some products it may be necessary to use a syringe to measure a part dose, or to prepare a solution that is not specifically manufactured for nebulisation. In this instance the practitioner must use the most suitable syringe type and necessary attachments to safely and securely handle the medicine for nebulisation. 

All syringes should be prepared and used immediately.  The practitioner preparing the medicine is responsible for ensuring nebulised medicines, as for all medicinal products, are administered to the correct patient, at the correct time, by the correct route.

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Nebuliser Assessment Guide (Adults only)

A formal assessment of response to nebulised medication should be performed prior to patients commencing long-term therapy.

There are two types of nebuliser assessment, due to differing potential for adverse drug reactions (particularly bronchospasm):

  1. Bronchodilator (salbutamol) nebuliser trial
  2. Nebulised antibiotics & hypertonic saline trial

Assessments for Cystic Fibrosis patients are co-ordinated with the CF Physiotherapists.

The integrated COPD Service provides bronchodilator nebuliser assessments for patients with known COPD. All referrals should be sent to the Leeds Integrated COPD service - Leeds Community Health Trust (leedsintegrated.copdservice@nhs.net).

Nebuliser assessments are performed by the Respiratory Nurse Specialist Team for both inpatient and outpatients patients referred from a respiratory consultant requiring a test dose of either nebulised antibiotics or hypertonic saline by emailing leedsth-tr.respiratorynurse@nhs.net

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Nebulised Antibiotics & Hypertonic Saline Trial: Sodium Chloride 7% (Resp-Ease®), Tobramycin or Colomycin® (Respiratory Adult Patients Only)

Appointment 1:
The patient attends the Respiratory Day Unit, and is reviewed by the Respiratory Day Unit nurse. 

The specialist respiratory nurse is responsible for:

  • Explaining the purpose of the appointment.
  • Providing written information regarding the nebulised treatment, comprising a copy of the Adult Nebuliser Information Leaflet (Appendix 2), and a copy of the LTH Antibiotic patient information leaflets (available for Colomycin® - Appendices 4) and any provided by the manufacturer.
  • Performing the nebuliser trial and assessment using the following flow chart:

1. Record the following observations in patient’s medical notes:

2. Check allergy status and results from the MRSA screen, and ensure these are recorded on the Nebuliser Assessment Prescription Referral & Administration Record (appendix 7).

3. Explain the purpose of the nebuliser treatment to the patient. This includes the use and action of the medication and potential side effects

4. Check the medication against the prescription chart and with the patient’s ID bracelet.

5. Demonstrate how to assemble the compressor and nebuliser, and how to prepare the medication, and how to recognise when treatment is completed.

  • Check the patient’s understanding by assessing the patient’s ability to assemble the nebuliser and prepare the medication for their test dose

6. Administer the first dose of nebulised antibiotic or hypertonic saline to the patient, and observe the patient throughout the duration of treatment to observe for any adverse reactions.

7. Recheck the FEV1 (Forced Expiratory Volume in 1 Second) 15 and 30 minutes after the end of the nebuliser treatment, and calculate the actual change (L) and percentage (%) change in FEV1 from baseline. Record these on the Nebuliser Assessment Prescription Referral & Administration Record (appendix 7)

  • If the post-nebulisation FEV1 has not fallen by more than 200mL or 15% compared to baseline, this is a pass.
  • If the post-nebulisation FEV1 has fallen by more than 200mL or 15% compared to baseline, this is a fail.
    • If a fail - Contact the Specialist Registrar on call for medical review. Administer prescribed bronchodilator and ensure FEV1 has to baseline post prior to discharge.

8. After the nebuliser has finished, rinse the nebuliser, and check that the patient can correctly assemble the nebuliser.

9. Provide instructions to the patient about cleaning, care and maintenance of the compressor, and how to obtain replacement supplies of disposable parts (appendix 2).

10. Discharge the patient

11. Dictate letter to the patient’s GP, and CC it to their Consultant and the patient.

12. Document outcome of the review in the medical notes.

 

If the patient is having a Colomycin® or tobramycin trial, ensure they are given the following items to take home:

  • Sharps bin
  • 2mL or 5mL Syringes
  • Blunt filter needles
  • Appropriate diluents (sodium chloride 0.9%)
  • SideStream plus nebuliser kit
  • SideStream Plus Filters or elephant tubing
  • Compressor, e.g. Phillips InnoSpire Deluxe
  • Discharge prescription’s (2 week supply of medication)

It is the responsibility of the clinician who prescribes the on-going nebulised medication to supply replacement equipment to facilitate this administration, This will usually be the GP, in line with the amber guidance.

If the patient is having a hypertonic saline trial, ensure they are given the following items to take home:

  • SideStream nebuliser kit
  • Compressor, e.g. Phillips InnoSpire Deluxe
  • Discharge prescription’s (2 weeks supply of medication)

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Individual Drug Monographs

ACETYLCYSTEINE

Mode of action

Mucolytic agent that is prescribed to facilitate expectoration in patients with bronchiectasis or other causes of increased sputum viscosity.

Dosage

2mLs (400mg) mixed with 2mLs sodium chloride 0.9% TDS-QDS

Strengths available

200mg/mL - 10mL vials (Parvolex®)

Compatible nebuliser(s)

Use SideStream Plus with filter attachment

Flow rate

6-8 litre/min

Filter needed?

Yes - single use only

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Can cause bronchospasm. Administer a bronchodilator prior to administration of next dose if patient experiences bronchospasm.  If bronchospasm continues stop nebulised acetylcysteine.

Notes
  • Oxygen should not be used as the driving gas as this can lead to de-activation of the acetylcysteine - use compressed air only1
  • Acetylcysteine must not be nebulised through a ventilator circuit.
  • Discard any solution remaining in the 10mL vial.

References
  • Lawson D, Saggers BA (1965). NAC and antibiotics in cystic fibrosis. British Medical Journal; 1 (5430): 317

Links

 

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ADRENALINE

Mode of action

Used for haemoptysis or stridor due to airway inflammation

Dosage

Adrenaline 1 in 1000 (1mg in 1mL) diluted to 5mL with sodium chloride 0.9% (usually QDS)

Strengths available

Adrenaline 1 in 1000 must be used

Compatible nebuliser(s)

SideStream

Flow rate

6-8 litre/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Adverse effects, e.g. tremor and tachycardia

Notes
  • Alternative strengths of adrenaline are not appropriate

References

-

Links

-

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AMIKACIN (Injectable preparation)

Mode of action

Used in cystic fibrosis as part of long-term antibiotic regimens for the treatment of rapid growing atypical mycobacterium, e.g. M. abscessus1

The role of nebulised antibiotics in non-cystic fibrosis patients with non-tuberculosis mycobacterial disease has not been established and treatment with intravenous antibiotics is preferred2.

Dosage

500mg twice daily; the 250mg/mL injection should be used and made up to 4mLs with sodium chloride 0.9%

Strengths available

250mg/mL injection should be used

Compatible nebuliser(s)

Use SideStream Plus with filter attachment, or Pari LC Plus (not with Philips Compressor)

  • SideStream Plus with filter attachment is nebuliser of choice.

Flow rate

6-8 litres/min

Filter needed?

Yes

Compatibility

See compatibility chart

Monitoring

Lung function pre and post initial test dose

Notes
  • Prior to administration the patient should receive a bronchodilator, e.g. salbutamol, as this will reduce the risk of coughing and bronchospasm.  This can be given nebulised or by their regular inhaler.
  • Patients with excess secretions should be given their nebulised antibiotics after physiotherapy to aid chest clearance.
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function

References
  1. Cullen AR, Cannon CL, Mark EJ et al (2000) Mycobacterium abscessus infection in CF: colonisation or infection? American Journal of Respiratory and Critical Care Medicine; 161: 641-645
  2. Griffith DE, Askamit T, Brown-Elliott BA et al (2007) An Official ATS/IDSA Statement: Diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases.  American Journal of Respiratory and Critical Care Medicine; 175(4): 367-416.

Links

- https://www.nice.org.uk/advice/es36/resources/antimicrobial-prescribing-nebulised-liposomal-amikacin-pdf-1158239633605

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AMIKACIN LIPOSOMAL (ARIKAYCE LIPOSOMAL)

Mode of action

Used in the treatment of non-tuberculous mycobacterial (NTM) lung infections caused by Mycobacterium avium Complex (MAC) in adults with limited treatment options who do not have cystic fibrosis.

It is used in accordance with the NHS England Commissioning Policy only (publication anticipated Summer 2022)

Dosage

One vial (590 mg) administered once daily, by oral inhalation

Strengths available

Not specified,

Each vial contains amikacin sulfate equivalent to 590 mg amikacin in a liposomal formulation. The mean delivered dose per vial is approximately 312 mg of amikacin

Compatible nebuliser(s)

Pari e-Base (supplied by Insmed)

  • Inhaled liposomal amikacin must only be used with the Lamira Nebuliser System (nebuliser handset, aerosol head and controller).
  • Each pack of 28 vials also contains the Lamira Nebuliser Handset and 4 aerosol heads.

Flow rate

N/A

Filter needed?

No

Compatibility

The Lumira Nebuliser system is only compatible with Arikayce. Other drugs must not be mixed together.

Monitoring

Lung function pre and post initial test dose is recommended

Notes
  • Bronchospasm has been reported with the use of inhaled liposomal amikacin in clinical studies.
  • In patients with a history of reactive airway disease, asthma or bronchospasm, inhaled liposomal amikacin should be administered after using a short-acting bronchodilator (e.g. salbutamol).
  • If there is evidence of bronchospasm due to inhaled liposomal amikacin inhalation, the patient may be pre-treated with bronchodilators (e.g. salbutamol).

References
  1. Griffith DE, Eagle G, Thomson R et al. Amikacin Liposome Inhalation Suspension for Treatment-Refractory Lung Disease Caused by Mycobacterium avium Complex (CONVERT). Am J Respir Crit Care Med. 2018;198(12):367-416.

Links

-       https://www.medicines.org.uk/emc/product/12067
-        NICE Evidence summary [ES36]. Antimicrobial prescribing: nebulised liposomal amikacin. May 2021. Available at:. https://www.nice.org.uk/advice/es36/chapter/Product-overview

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AMPHOTERICIN (AMBISOME®)

Mode of action

Antifungal agent for prophylaxis against pulmonary aspergillosis

Dosage

Cystic fibrosis patients - 25mg twice daily; each 50mg vial is made up with 12mLs water for injection

Non-cystic fibrosis patients - lower doses may be used, e.g. antifungal prophylaxis in patients with haematological malignancies a dose of 12.5mg twice daily is recommended1.

Strengths available

50mg vial for reconstitution

Compatible nebuliser(s)

Use SideStream Plus with filter attachment, or Pari LC Plus (not with Philips Compressor)

  • Pari LC Plus; latter is nebuliser of choice due to fill volume

Flow rate

6-8 litre/min

Filter needed?

Yes

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Can cause bronchospasm.  Administer a bronchodilator prior to administration of next dose if patient experiences bronchospasm.  If bronchospasm continues stop nebulised amphotericin.
  • On the initial dose pre and post dose monitoring of lung function

Notes
  • Liposomal amphotericin (Ambisome) should be prescribed and not the non-lipid amphotericin (Fungizone)
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function
  • This should be prepared by Pharmacy Aseptics.  If required between the hours of 9am and 5pm then please contact your ward pharmacist.  Out-of-hours please bleep the on-call pharmacist on 80-1247

References
  1. Cornely OA, Böhme A, Buchheidt D et al (2009). Primary prophylaxis of invasive fungal infections in patients with hematologic malignancies. Recommendations of the Infectious Diseases Working Party of the German Society for Haematology and Oncology. Haematologica; 94:113-122

Links

-

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AZTREONAM LYSINE

Mode of action

For use in restricted cystic fibrosis patients only.

Approved in LTHT for patients who are chronically colonised with Pseudomonas aeruginosa, and are intolerant of other nebulised antibiotics (Promixin and Tobi), or who have chronic infection with multi or pan-resistant Pseudomonas aeruginosa and show continuing clinical deterioration and lack of response to intravenous antibiotic therapy.

Dosage

75mg three times a day

Strengths available

Supplied as 75mg vial for reconstitution with included diluent (sodium chloride 0.17%)

Compatible nebuliser(s)

Specific eFlow

(please note this is a specific eFlow for aztreonam lysine and not the standard eFlow that is available - it is included with the initial supply of aztreonam lysine from the company)

Cayston should only be used with the Altera Nebuliser Handset and Altera Aerosol Head connected to an eBase Controller or an eFlow rapid Control Unit.

Flow rate

N/A over a 2-3 minute period

Filter needed?

Yes

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Can cause bronchospasm

Notes
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function
  • Patients should use a bronchodilator before each dose of Cayston. Short acting bronchodilators can be taken between 15 minutes and 4 hours and long acting bronchodilators can be taken between 30 minutes and 12 hours prior to each dose of Cayston.
  • Patients with excess secretions should be given their nebulised antibiotics after physiotherapy to aid chest clearance.
  • Aztreonam lysine may be considered if there is still progressive loss of lung function (defined as greater than 2% per year decline in FEV1 as % of predicted) or there is continued need for IV therapy for exacerbations i.e. more than 2 per year despite therapy with an alternating regimen of tobramycin and colistin. This may be prescribed either alternating with colistimethate sodium or tobramycin depending on the clinical response to those medications previously

References

-

Links

http://www.medicines.org.uk/EMC/medicine/22358/SPC/Cayston+75+mg+
powder+and+solvent+for+nebuliser+solution/

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BUDESONIDE

Mode of action

Corticosteroid - reduces inflammation in the lungs

Dosage

500 micrograms to 2mg twice daily

Strengths available

500 micrograms/2mL
1mg/2ml

Compatible nebuliser(s)

SideStream

Flow rate

6-8 litre/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Irritation to mouth and throat

Notes
  • Patients should receive their bronchodilators (if prescribed as regular treatment) 5-10 minutes before the nebulised anti-inflammatory
  • Patients should rinse their mouth after use.  This reduces irritation to the mouth and throat.
  • There is no clinical data to suggest a superiority of nebulised corticosteroids over inhaled corticosteroids.  Subsequently these should only be initiated after a senior respiratory specialist review1.

References
  1. Boe J, Dennis JH, O’Driscoll BR et al (2001) European respiratory Society Guidelines on the use of nebulizers.  European Respiratory Journal; 18: 228-242

Links

http://www.medicines.org.uk/emc/document.aspx?documentId=2471

 

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BUPIVACAINE

Mode of action

For the treatment of intractable cough

Dosage

2ml-5ml of the 0.25% solution

Strengths available

The 0.25% solution must be used

Compatible nebuliser(s)

SideStream

Flow rate

6-8 litres/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring

Care should be taken to ensure the patient can swallow adequately before anything is given orally after nebulised bupivacaine

Notes
  • Use 5-10 minutes after an inhaled bronchodilator, e.g. salbutamol.  This reduces the risk of coughing and bronchospasm
  • Patients should avoid hot food and drinks for 2 hours after inhalation of bupivacaine as pharyngeal numbness can occur1.

References
  1. McAlpine L & Thomson N (1989) Lidocaine-induced bronchoconstriction in asthmatic patients. Relation to histamine airway responsiveness and effect of preservative. Chest. 96: 1012–1015

Links

-

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COLISTIMETHATE SODIUM (COLOMYCIN®)
Please note there are two colistimethate sodium products please ensure you select the correct one

Mode of action

Antibiotic use for the eradication of recent pulmonary colonisation with Pseudomonas aeruginosa in patients with non-CF bronchiectasis.1

Long-term therapy in patients with non-CF bronchiectasis who are chronically colonised with Pseudomonas aeruginosa, who have >3 exacerbations per year requiring antibiotic therapy or have fewer exacerbations that are causing significant morbidity.1

Dosage

2,000,000 units (2 Megaunits,MIU) twice a day

Strengths available

2,000,000 units (2 Megaunits,MIU) injection

Compatible nebuliser(s)

Use SideStream Plus with filter attachment

Flow rate

6-8 litres/min

Filter needed?

Yes

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Can cause bronchospasm

Notes
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function
  • Patients with excess secretions should be given their nebulised antibiotics after physiotherapy to aid chest clearance.
  • Hypertonic solutions of colistimethate sodium can cause bronchospasm. In order to avoid this, each dose is made up with 2mLs water for injections and 2mLs sodium chloride 0.9%.
  • Each vial of colistimethate sodium can be reconstituted with 2.5 mg/2.5mL of salbutamol if the above solutions have caused bronchoconstriction

References
  1. Pasteur MC, Bilton D, Hill AT. British Thoracic Society guideline for non-CF bronchiectasis. Thorax 2010;65(suppl I):i1-i58.

Links

http://www.medicines.org.uk/emc/document.aspx?documentid=1590&docType=SPC

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COLISTIMETHATE SODIUM (PROMIXIN®)
Please note there are two colistimethate sodium products please ensure you select the correct one

Mode of action

FOR CYSTIC FIBROSIS PATIENTS ONLY

Antibiotic use for the eradication of recent pulmonary colonisation with Pseudomonas aeruginosa and as long term use for chronic pulmonary Pseudomonas aeruginosa infection

Dosage

1,000,000 units (1 Megaunits,MIU) twice a day

Strengths available

1,000,000 units (1 Megaunits,MIU) vial

Compatible nebuliser(s)

I-neb

Flow rate

N/A

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Can cause bronchospasm.  Administer a bronchodilator prior to administration of next dose if patient experiences bronchospasm.  If bronchospasm continues stop nebulised Promixin.

Notes
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function
  • Patients with excess secretions should be given their nebulised antibiotics after physiotherapy to aid chest clearance.
  • The maximum fill volume of the I-neb is only 1mL
  • The vial of Promixin should be diluted with 1mL water for injection

References

-

Links

http://www.medicines.org.uk/emc/document.aspx?documentid=13495&docType=SPC

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DORNASE ALFA

Mode of action

FOR CYSTIC FIBROSIS PATIENTS ONLY
Mucolytic agent used in the management of cystic fibrosis

Dosage

2500 units (2.5mg) daily

  • some patients over the age of 21 may benefit from twice daily dosing

Strengths available

2500 units(2.5mg)/2.5mL

Compatible nebuliser(s)

I-neb, eFlow or SideStream

Flow rate

6-8 litres/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Adverse reactions, e.g. chest pain (pleuritic/ non cardiac), pharyngitis, dyspnoea, voice alteration (hoarseness), laryngitis, fever, rash, dyspepsia and conjunctivitis

Notes
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function
  • Inhaled antibiotics must not be used within one hour of dornase alfa therapy as the antibiotic may denature the protein structure of dornase alfa1.

References
  1. Conway S & Littlewood J (1997). RhDnase in Cystic Fibrosis. British Journal of Hospital Medicine; 57 (8): 371-372.

Links

http://www.medicines.org.uk/emc/document.aspx?documentid=1723&docType=SPC

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FLUTICASONE

Mode of action

Corticosteroid - reduces inflammation in the lungs

Dosage

500 micrograms to 2mg twice daily

Strengths available

500 micrograms/2mL

2mg/2mL

Compatible nebuliser(s)

SideStream

Flow rate

6-8 litres/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Irritation to mouth and throat

Notes
  • Patients should receive their bronchodilators (if prescribed as regular treatment) 5-10 minutes before the nebulised anti-inflammatory
  • Patients should rinse their mouth after use.  This reduces irritation to the mouth and throat.
  • There is no clinical data to suggest a superiority of nebulised corticosteroids over inhaled corticosteroids.  Subsequently these should only be initiated after a senior respiratory specialist review1.

References
  1. Boe J, Dennis JH, O’Driscoll BR et al (2001) European respiratory Society Guidelines on the use of nebulizers.  European Respiratory Journal; 18: 228-242

Links

http://www.medicines.org.uk/emc/document.aspx?documentid=6326&docType=SPC

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GENTAMICIN

Mode of action

Aminoglycoside antibiotic for prophylaxis against pseudomonas aeruginosa infection

Long-term therapy in patients with non-CF bronchiectasis who are chronically colonised with Pseudomonas aeruginosa, who have >3 exacerbations per year requiring antibiotic therapy or have fewer exacerbations that are causing significant morbidity.1

Dosage

80mg twice daily

Strengths available

40mg/mL and 80mg/2mL; this is the intravenous injection which can be nebulised

Compatible nebuliser(s)

Use SideStream Plus with filter attachment

Flow rate

6-8 litres/min

Filter needed?

Yes

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Monitor for hypersensitivity - if chest tightness occurs inform a doctor immediately

Notes
  • Prior to administration the patient should receive a bronchodilator, e.g. salbutamol, as this will reduce the risk of coughing and bronchospasm
  • Patients with excess secretions should be given their nebulised antibiotics after physiotherapy to aid chest clearance.
  • Patients with excess secretions should be given their nebulised antibiotics after chest clearance
  • The 80mg dose should be diluted with sodium chloride 0.9% to a volume of 4mLs

References
  1. Pasteur MC, Bilton D, Hill AT. British Thoracic Society guideline for non-CF bronchiectasis. Thorax 2010;65(suppl I):i1-i58.

Links

-

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IPRATROPIUM

Mode of action

Short-acting anticholinergic that acts by directly antagonising all subtypes of muscarinic receptors in nerve-endings and airway smooth muscle

Dosage

250micrograms to 500 micrograms QDS; there is no evidence to support the use of higher doses1

Strengths available

250 micrograms/1mL
500 micrograms/2mL

Compatible nebuliser(s)

SideStream

Flow rate

6-8 litre/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Urine output - rarely causes urinary retention

Notes
  • A patient should not be prescribed ipratropium and a long-acting muscarinic antagonist (e.g. tiotropium, aclidinium, glycopyrronium or umeclidinium)
  • For doses of less than 500 micrograms, if used alone, dilute with sodium chloride 0.9% to a volume of 2-4mLs.
  • Never use a mask to administer nebulised ipratropium to a patient with glaucoma2

References
  1. Whyte KF, Gould GA, Jeffrey AA et al (1991).  Dose of nebulised ipratropium bromide in acute severe asthma.  Respiratory Medicine; 85: 517-520
  2. Boe J, Dennis JH, O’Driscoll BR et al (2001) European respiratory Society Guidelines on the use of nebulizers.  European Respiratory Journal; 18: 228-242

Links

http://www.medicines.org.uk/emc/document.aspx?documentid=2797&docType=SPC

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LEVOFLOXACIN - QUINSAIR®

Mode of action

FOR CYSTIC FIBROSIS PATIENTS ONLY

Antibiotic used for the management of chronic pulmonary infections due to Pseudomonas aeruginosa.

Levofloxacin and other fluoroquinolone antimicrobials inhibit bacterial DNA gyrase and topoisomerase IV enzymes.

Dosage

240mg (one ampule) twice a day.

The doses should be inhaled as close as possible to 12 hours apart, for 28 days on followed by 28 days off treatment.

Strengths available

Each ampule contains 240mg levofloxacin (1ml nebuliser solution contains levofloxacin hemihydrate equivalent to 100 mg of levofloxacin)

Compatible nebuliser(s)

Zirela Nebuliser Handset (including a Zirela Aerosol Head) provided in the pack connected to an eBase Controller or an eFlow rapid Control Unit

Flow rate

N/A

Filter needed?

No

Compatibility

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

For patients taking multiple inhaled therapies, the recommended order of administration is as follows:

1. Bronchodilators;
2. Dornase alfa;
3. Airway clearance techniques;
4. Quinsair (levofloxacin)
5. Inhaled steroids.

Monitoring
  • Clinical response
  • Hypersensitivity reactions

Can cause bronchospasm

Notes
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function
  • A short-acting bronchodilator can be used 15 minutes to 4 hours prior to administration to reduce the risk of bronchospasm
  • 1 dose takes 5 minutes to complete via Zirela device
  • Levofloxacin is systemically absorbed following inhalation of Quinsair® therefore all of the adverse effects associated with oral/intravenous administration of levofloxacin are a potential risk with the nebulised formulation see SPC for further details.    

References

-

Links

https://www.medicines.org.uk/emc/product/7202/smpc

https://www.england.nhs.uk/wp-content/uploads/2018/08/Levofloxacin-nebuliser-solution-for-chronic-
Pseudomonas-lung-infection-in-cystic-fibrosis-adults.pdf

https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-new-restrictions-and-precautions-for-use-due-to-very-
rare-reports-of-disabling-and-potentially-long-lasting-or-irreversible-side-effects?UNLID=101680642720211014163723

https://www.gov.uk/drug-safety-update/systemic-and-inhaled-fluoroquinolones-small-risk-of-heart-valve-regurgitation-
consider-other-therapeutic-options-first-in-patients-at-risk?UNLID=101680642720211014163723

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LIDOCAINE (LIGNOCAINE)

Mode of action

For the treatment of intractable cough.

Dosage

2-5mL of the 2% injection

Strengths available

The 2% injection must be used

Compatible nebuliser(s)

SideStream

Flow rate

6-8 litres/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Care should be taken to ensure the patient can swallow adequately before anything is given orally after nebulised lidocaine.

Notes
  • Use 5-10 minutes after an inhaled bronchodilator, e.g. salbutamol.  This reduces the risk of coughing and bronchospasm
  • Patients should avoid hot food and drinks for 2 hours after inhalation of lidocaine as pharyngeal numbness can occur1.

References
  1. McAlpine L & Thomson N (1989) Lidocaine-induced bronchoconstriction in asthmatic patients. Relation to histamine airway responsiveness and effect of preservative. Chest. 96: 1012–1015

Links

-

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MEROPENEM

Mode of action

Antibiotic used in cystic fibrosis patients for chronic Mycobacteria abscessus/Mycobacteria chelonae in patients who are intolerant/allergic to nebulised tobramycin or clinically failing on nebulised amikacin 

Dosage

250mg twice daily in 5mL water for injection

Strengths available

500mg injection

Compatible nebuliser(s)

Use SideStream Plus with filter attachment

Flow rate

6-8 L/min

Filter needed?

Yes

Compatibility

Only known to be compatible with water for injection

Monitoring
  • Clinical response
  • Can cause bronchospasm.  Administer a bronchodilator prior to administration of next dose if patient experiences bronchospasm.  If bronchospasm continues stop nebulised amphotericin.
  • On the initial dose pre and post dose monitoring of lung function

Notes
  • Prior to administration the patient should receive a bronchodilator, e.g. salbutamol, as this will reduce the risk of coughing and bronchospasm.  This can be given nebulised or by their regular inhaler.
  • Patients with excess secretions should be given their nebulised antibiotics after physiotherapy to aid chest clearance.
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function
  • There have been reports of teeth being stained black with nebulised meropenem and it is important to advise patients to brush teeth regularly and to have regular dental appointments.

References

-

Links

-

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PENTAMIDINE

Mode of action

Treatment of and prophylaxis against infection with Pneumocystis carinii pneumonia (PCP).  First line treatment is intravenous or oral high-dose co-trimoxazole or pentamidine; these are more effective than nebulised pentamidine and a more rapid response to treatment is obtained1

Dosage

Prophylactic dose: 300mg monthly

Treatment dose: 600mg daily

Strengths available

The 300mg vial (powder for reconstitution) is used for both prophylactic and treatment regimens - this needs to be prepared by aseptics.

Compatible nebuliser(s)
  • Respirgard II jet nebulizer system

Alternatives:

  • Pari Plus with filter attachment, if using Pari Boy Compressor

or

  • SideStream Plus with filter attachment, if using piped oxygen at 5-7L/min


Administer using piped oxygen at 5-7L/min, or a suitable air compressor.
Suitable compressors include the Pari Boy.

Low-pressure (i.e. less than 20 PSI) air compressors should not be used

Flow rate

6-8 litre/min

Filter needed?

Yes

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Measurement of PEFR (peak expiratory flow rate) is recommended pre and post pentamidine.  If bronchoconstriction occurs (significant fall in PEFR, shortness of breath, wheezing) inform a doctor immediately who may prescribe a ß2-agonist (as a second dose in addition to the initial dose given prior to administering of pentamidine).

Notes
  • Use 5-10 minutes after administration of a ß2-agonist nebuliser, e.g. salbutamol.  This reduces the risk of coughing and bronchospasm whilst maximising delivery to the lungs
  • Reconstitution:
    • This must be prepared by Pharmacy Aseptics.
  • Health and Safety:
    • Pregnant health care workers should avoid exposure to pentamidine
    • Store in a cool, dry place (vials are combustible in sufficient quantities)
    • Ensure patient is in a well-ventilated area away from other patients, i.e. in side-room with window open
    • Where it is not possible to open windows a negative pressure room should be used and should be left unused for at least 1 hour following the procedure (ensures 4 air changes)
    • Health care workers should wear gloves and a mask (FFP3) when reconstituting and administering.  Dispose of into a yellow clinical waste sack.  If a patient is happy and knows what to do you can leave the room during nebulisation
    • The nurse in charge of the procedure must inform all staff that they must not enter the room and should place a sign on the door stating ‘Please do not enter this room, see staff nurse’
    • A risk assessment should be made to ensure that it is safe to leave the patient during the 20-45 minute nebulisation time, and that they are able to call staff urgently if needed.  No observations are required during this time
  • Administration
    • Self-administration is preferred.
    • When inhalation of ß2-agonist nebuliser, e.g. salbutamol, has completed explain to the patient the treatment.  Ensure they understand how to turn on the air and insert the pentamidine into the nebuliser 
    • The nurse will leave the room and the patient will insert the prescribed pentamidine into the nebuliser chamber and dispose of the cartridge in the clinical waste bag
    • If the patient is unable to self-administer or a member of staff needs to enter the room during the nebuliser administration or within an hour after the nebuliser has finished, a FFP3 mask +/- visor should be worn
    • The patient will now seal their mouth around the mouth piece of the nebuliser and turn the air valve to 7 or 8, the patient is then to breath normally taking in the pentamidine, the treatment should take approximately 20-45 minutes
    • Before the patient commences treatment the nurse must have left the room, leaving further instructions as to when the treatment is complete. 
    • A clear sign should be placed on the closed door of the patient’s room stating the start time, end time of the nebuliser and the time it is safe to enter
    • The patient must place the used nebuliser mask and tubing into the clinical waste bag.
  • Re-entering the patient’s room:
    • For negative pressure rooms and side rooms: staff should wait up to 1 hour before re-entering the room after the pentamidine dose has finished.
    • For side rooms, the window should be left open for an hour after the dose.
  • If the patient needs to cough or spit out excess saliva switch-off the compressor first to prevent any pentamidine escaping.  Saliva should be expectorated into a sputum pot
  • Nebulised pentamidine has an unpleasant taste.  A strong flavoured sweet (liquorice, aniseed, mint) may be sucked prior to and following administration

References
  1. British Thoracic Society (1997) Current best practice for nebuliser treatment.   Thorax; 52 (supplement 2): S4-S16

Links

http://www.medicines.org.uk/emc/document.aspx?documentid=949&docType=SPC

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RIBAVIRIN

Mode of action

Treatment of Human Para influenza Viruses and Human Respiratory Syncytial Virus (RSV) - should only be started after consultation with virologist

Dosage

A 20mg/mL solution should be nebulised for 3 periods of 2 hours per day (giving a total daily dose of 6g) for at least 3 days; maximum 7 days.

Sometimes the timing of infusions can change to fit in with nursing staff, e.g. 3g over 3 hours twice a day is sometime used - the total daily dose remains the same.

Strengths available

6g powder for inhalation .

This must be prepared by Pharmacy Aseptics, with a 24 hour expiry (one 6g bottle is used for 24 hours and so it is best initiated at evening dose)

Compatible nebuliser(s)

Aiolos (available from BMTU - SJUH)

Flow rate

6-8 litres/min

Filter needed?

Yes

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • U&E’s
  • Can cause bronchospasm

Notes
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function
  • This must be prepared by Pharmacy Aseptics.  If required between the hours of 9am and 5pm then please contact your ward pharmacist.  Out-of-hours please bleep the on-call pharmacist on 80-1247.
  • Ribavirin is classified as a ‘Substance Hazardous to Health’ under the COSHH regulations 1994 and should only be administered by those experienced in its use.
  • Health care workers should wear gloves and a mask (code number FFP1) when reconstituting and administering.  Dispose of into a yellow clinical waste sack.  If a patient is happy and knows what to do you can leave the room during nebulisation.
  • Pregnant women (and those planning pregnancy) should avoid exposure to aerosol.
  • The manufacturer’s product literature should be read prior to administering nebulised ribavirin

References

-

Links

http://www.medicines.org.uk/emc/document.aspx?documentid=866&docType=SPC

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SALBUTAMOL

Mode of action

Short-acting bronchodilator - β2-agonist that relaxes smooth muscle directly by stimulation of β2-receptors and indirectly by reducing acetylcholine release

Dosage

2.5mg to 5mg; frequency can vary from continuous in severe asthma exacerbations to only using when required

Strengths available

2.5mg/2.5mLs
5mg/5mLs
Also present within Combivent® solution for nebulisation (contain 2.5mg salbutamol and 500 micrograms ipratropium)

Compatible nebuliser(s)

SideStream

Flow rate

6-8 litre/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Adverse effects, e.g. tremor, tachycardia

Notes
  • First line bronchodilator within LTHT
  • If a patient is not on regular nebulisers at home their nebulised bronchodilators must be stopped for at least 24 hours prior to discharge from hospital1,2
  • The adverse effects of bronchodilator therapy are pharmacologically predictable and dose-dependent

References
  1. Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2009). Global Strategy for the Diagnosis, Management and Prevention of COPD. Available from: http://www.goldcopd.org.
  2. Scottish Intercollegiate Guidelines Network (2008).  British Guideline on the Management of Asthma. Available from http://www.sign.ac.uk.

Links

http://www.medicines.org.uk/emc/document.aspx?documentid=102&docType=SPC

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SODIUM CHLORIDE 0.9%

Mode of action

Mucolytic agent

Dosage

2.5mL-5mL from six hourly to when required

Strengths available

2.5mL solution for nebulisation

Compatible nebuliser(s)

SideStream

Flow rate

6-8 litres/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Can cause bronchospasm

Notes
  • Administer a bronchodilator prior to administration of next dose if patient experiences bronchospasm

References

-

Links

-

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SODIUM CHLORIDE 6% (MucoClearÒ)

Mode of action

Mucolytic agent and also used for induced sputum sampling

NB. Although this preparation is available, Resp-Ease® Ò is the preferred choice at LTHT (see below)

Dosage

4mL twice daily

Strengths available

Mucoclear - 4mL plastic ampoules of 6% solution

Compatible nebuliser(s)

Non Cystic Fibrosis patients - SideStream

Cystic Fibrosis patients only - I-neb or eFlow

Flow rate

6-8 litres/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Can cause bronchospasm

Notes
  • A nebulised bronchodilator should be administered prior to administration
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function

References

-

Links

 

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SODIUM CHLORIDE 7% (Resp-EaseÒ)

Mode of action

Mucolytic agent and also used for induced sputum sampling

 

Dosage

4mL twice daily

Strengths available

Resp-Ease - 4mL plastic ampoules of 7% solution

Compatible nebuliser(s)

Non Cystic Fibrosis patients - SideStream

Cystic Fibrosis patients only - I-neb or eFlow

Flow rate

6-8 litres/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Can cause bronchospasm

Notes
  • A nebulised bronchodilator should be administered prior to administration
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function
  • Resp-Ease® is used in preference to Nebusal® as it is a cheaper identical product.

References

-

Links

 

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TAUROLIDINE

Mode of action

FOR CYSTIC FIBROSIS PATIENTS ONLY

An antibiotic and an anti-endotoxin with a broad spectrum of activity against Gram negative and positive bacteria and fungi

Dosage

3-4mLs of 2% solution twice daily

Strengths available

2% solution must be used - the bottle may be used for 1 week and then the remaining solution is discarded.

It is good practice to write the date that the bottle was opened on the label.

Compatible nebuliser(s)

Pari LC Plus (not with Philips compressor):

  • Pari LC Plus and filters available from supplies (NHS Logistics) - pack size = 1 (Catalogue code FDE 265)
  • Pari LC Plus filters (Catalogue code FDE302)

Flow rate

6-8 litres/min

Filter needed?

Yes

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Monitor renal function as care is advised in patients with renal insufficiency
  • May cause bronchospasm, cough or mild ‘burning’ sensation in the throat

Notes
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function
  • Unlicensed product, available as an intra-peritoneal lavage on a named patient basis

References

-

Links

 

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TERBUTALINE

Mode of action

Short-acting bronchodilator - β2-agonist that relaxes smooth muscle directly by stimulation of β2-receptors and indirectly by reducing acetylcholine release

Dosage

5mg to 10mg; frequency can vary from continuous in severe asthma exacerbations to only using when required

Strengths available

5mg/2mL (Bricanyl Respules®)

Compatible nebuliser(s)

SideStream

Flow rate

6-8 litre/min

Filter needed?

No

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Potassium level
  • Adverse effects, e.g. tremor, tachycardia

Notes
  • Salbutamol is the first line nebulised bronchodilator within LTHT.  Terbutaline is second line.
  • If a patient is not on regular nebulisers at home their nebulised bronchodilators must be stopped for at least 24 hours prior to discharge from hospital1,2
  • The adverse effects of bronchodilator therapy are pharmacologically predictable and dose-dependent

References
  1. Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2009). Global Strategy for the Diagnosis, Management and Prevention of COPD. Available from: http://www.goldcopd.org.
  2. Scottish Intercollegiate Guidelines Network (2008).  British Guideline on the Management of Asthma. Available from http://www.sign.ac.uk.

Links

http://www.medicines.org.uk/emc/document.aspx?documentid=156&docType=SPC

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TOBRAMYCIN (Injectable preparation)

Mode of action

Aminoglycoside antibiotic for prophylaxis against pseudomonas aeruginosa infection.

Long-term therapy in patients with non-CF bronchiectasis who are chronically colonised with Pseudomonas aeruginosa, who have >3 exacerbations per year requiring antibiotic therapy or have fewer exacerbations that are causing significant morbidity.1

Dosage

160mg twice daily

Strengths available

The tobramycin injection should be used and administered via a nebuliser; available as 40mg/mL, 80mg/2mL and 240mg/6mL

Only cystic fibrosis patients can be prescribed the TOBI® solution for nebulisation (300mg/5mL)

Compatible nebuliser(s)

Use SideStream Plus with filter attachment

Flow rate

6-8 litres/min

Filter needed?

Yes

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Can cause bronchospasm

Notes
  • Prior to administration the patient should receive a bronchodilator, e.g. salbutamol, as this will reduce the risk of coughing and bronchospasm.
  • Patients with excess secretions should be given their nebulised antibiotics after physiotherapy to aid chest clearance.
  • If dose is less than 160 mg dilute with sodium chloride 0.9% to a volume of 4mLs
  • Patients on nebulised tobramycin do not routinely require tobramycin levels due to limited systemic absorption1.  If the patient is suspected to be experiencing tobramycin toxicity, e.g. ototoxicity or nephrotoxicity, then levels may be taken.  This should be a trough level

References
  1. Smith AL, Ramsey BW, Hedges DL et al (1989) Safety of aerosol tobramycin administration for 3 months to patients with cystic fibrosis.  Paediatric Pulmonology; 7: 265-271
  2. Pasteur MC, Bilton D, Hill AT. British Thoracic Society guideline for non-CF bronchiectasis. Thorax 2010;65(suppl I):i1-i58.

Links

-

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TOBRAMYCIN (TOBIÒ)

Mode of action

Aminoglycoside antibiotic for prophylaxis against Pseudomonas aeruginosa infection

Cystic Fibrosis: eradication of and prophylaxis against Pseudomonas aeruginosa infection

In non-CF bronchiectasis, Tobi® is reserved for patients who meet all three of the following criteria:

  1. They have grown a mucoid strain of P. aeruginosa from sputum or, if non-mucoid phenotype, have grown P. aeruginosa in 50% or more of sampled months in the past year (Leeds Criteria definition of chronic P. aeruginosa infection in CF).
  2. They have failed treatment with nebulised colistimethate sodium because they either:
    • are intolerant of nebulised colistimethate sodium e.g. due to bronchospasm, or allergy. or
    • grown P. aeruginosa resistant to colistimethate sodium, or
    • have not achieved treatment success with colistimethate sodium.
  3. Are intolerant of the intravenous tobramycin formulation when given by the nebulised route.

Dosage

300mg twice daily; this is usually given on a month-on-month-off rotation, rarely patients may receive continuously

Strengths available

TOBI® solution for nebulisation 300mg/5mL

Compatible nebuliser(s)

Pari LC Plus or eFlow

  • Pari LC Plus and filters available from supplies (NHS Logistics) - pack size = 1 (Catalogue code FDE 265)
  • Pari LC Plus filters (Catalogue code FDE302)

Flow rate

6-8 litres/min

Filter needed?

Yes

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Can cause bronchospasm

Notes
  • Prior to administration the patient should receive a bronchodilator, e.g. salbutamol, as this will reduce the risk of coughing and bronchospasm.
  • Patients with excess secretions should be given their nebulised antibiotics after physiotherapy to aid chest clearance.
  • If dose is less than 80 mg dilute with sodium chloride 0.9% to a volume of 2-4mLs
  • Patients on nebulised tobramycin do not routinely require tobramycin levels due to limited systemic absorption1.  If the patient is suspected to be experiencing tobramycin toxicity, e.g. ototoxicity or nephrotoxicity, then levels may be taken.  This should be a trough level

References
  1. Smith AL, Ramsey BW, Hedges DL et al (1989) Safety of aerosol tobramycin administration for 3 months to patients with cystic fibrosis.  Paediatric Pulmonology; 7: 265-271
  2. Pasteur MC, Bilton D, Hill AT. British Thoracic Society guideline for non-CF bronchiectasis. Thorax 2010;65(suppl I):i1-i58.

Links

http://www.medicines.org.uk/emc/document.aspx?documentid=19020&docType=SPC

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VANCOMYCIN

Mode of action

Used in patients who have grown Methicillin-Resistant Staphylococcus aureus (MRSA) in sputum

Dosage

250mg twice daily for 5 days

Strengths available

500mg and 1gram injection for reconstitution

Compatible nebuliser(s)

Use SideStream Plus with filter attachment

Flow rate

6-8 litres/min

Filter needed?

Yes

Compatibility

See compatibility chart

Monitoring
  • Clinical response
  • Can cause bronchospasm

Notes
  • Patients should have an initial supervised test dose with pre and post dose monitoring of lung function
  • Patients with excess secretions should be given their nebulised antibiotics after physiotherapy to aid chest clearance.
  • This is mainly used in cystic fibrosis patients and should not be routinely started on other wards.  It should only be initiated on microbiology advice
  • Reconstitution and administration:
    • 500mg Vial - mix one vial with 8mLs water for injection.  Using a syringe and needle draw up 4mLs of the vancomycin solution and put into the nebuliser chamber
    • 1 gram Vial - mix one vial with 16mLs water for injection.  Using a syringe and needle draw up 4mLs of the vancomycin solution and put into the nebuliser chamber

References

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Links

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MISCELLANEOUS

Several other antibiotics, including piperacillin-tazobactam, ceftazidime and temocillin have been approved by the Drug and Therapeutics Committee via a Chairman’s Action in paediatrics. 

These monographs have not been included as very specialist use via chairman’s action only.

 


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Provenance

Record: 2454
Objective:
Clinical condition:
Target patient group: Adults
Target professional group(s): Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

References for Compatibility Data

  1. British Thoracic Society (1997).  Nebuliser Therapy Guidelines.  Thorax; 52 (Supplement 2): S4-S24. Available at: http://thorax.bmj.com/content/52/suppl_2
  2. Boe J, Dennis JH, O’Driscoll BR et al (2001) European respiratory Society Guidelines on the use of nebulizers.  European Respiratory Journal; 18: 228-242.
  3. National Institute for Health and Clinical Excellence (2010) Management of Chronic Obstructive Pulmonary Disease in adults in primary and secondary care (partial update).  London. (Available at www.nice.org.uk)
  4. Anderson SD et al (1983) Evaluation of ultrasonically nebulised solutions for proactive testing in patients with asthma.  Thorax; 38: 284-291.
  5. O’Driscoll B R, Howard L S, Earis J, et al. BTS guideline for emergency oxygen use in adult patients. Thorax 2017; 72:i1-90 Supplement VI.
  6. British Thoracic Society / Scottish Intercollegiate Network (2016) British guideline on the management of asthma. Guideline No 63. Revised Edition June 16. Available at: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/
  7. British Thoracic Society (1997) Current best practice for nebuliser treatment.  Thorax. 52 (supplement 2): S1-S106. Available at: http://thorax.bmj.com/content/52/suppl_2
  8. Boe J, Dennis JH, O’Driscoll BR et al (2001) European respiratory Society Guidelines on the use of nebulizers.  European Respiratory Journal; 18: 228-242.
  9. Botman MJ, de Kreiger RA (1987) Contamination of small volume medication nebulizers and its association with oropharyngeal colonisation.  Journal of Hospital Infection; 10: 204-208.
  10. Kamin W, Schwabe A & Kramer (2006) Inhalation solution - which one are allowed to be mixed? Physico-chemical compatibility of drug solutions in nebulisers.  Journal of Cystic Fibrosis 5: 205-213
  11. UK Medicines Information (UKMi) (2007) Medicines Q&As: Which nebuliser solutions are compatible? (available online at www.nelm.nhs.uk; accessed 14/04/2008)
  12. Personal Communication.  Guy Oliver, Senior Medical Information Officer, Novartis (3rd January 2008)
  13. Roberts GW, Badcock NR, Jarvinen AO (1992) Cystic Fibrosis inhalation therapy: stability of combined salbutamol/colistin solution.  Australian Journal of Hospital Pharmacy 22(5): 378-380
  14. Lee T et al (2005) Compatibility and osmolality of inhaled N-acetylcysteine nebulizing solution with fenoterol and ipratropium.  American Journal of Health Systems Pharmacy 62(8): 828-833  
  15. Trissel LA.  Handbook on Injectable Drugs, 14th Edition (2006 online edition). American Society of Health-System Pharmacists, Bethesda, USA. Date accessed: 30/09/2008
  16. Personal Communication.  Martin Goldman, Senior Medical Advisor, Forest Laboratories Ltd (2nd January 2008)
  17. Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Pulmozyme) http://emc.medicines.org.uk/ (Date accessed: 03/11/2017; Date of last text revision: 21 April 2017). https://www.medicines.org.uk/emc/medicine/1723
  18. Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Promixin) http://emc.medicines.org.uk/ (Date accessed: 03/11/2017; Date of last text revision: 11/12/2015) https://www.medicines.org.uk/emc/medicine/13495
  19. Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Amikacin 250mg/mL Injection – Hospira UK Ltd) http://emc.medicines.org.uk/ (Date accessed: 03/11/2017; Date of last text revision: 08/2015) https://www.medicines.org.uk/emc/medicine/619
  20. Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Vancomycin 1g Powder for Solution for Infusion - Wockhardt UK Ltd) http://emc.medicines.org.uk/ (Date accessed: 03/11/2017; Date of last text revision: 24/02/2017) https://www.medicines.org.uk/emc/medicine/20835
  21. Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Tobramycin 40mg/mL Injection – Hospira UK Ltd) http://emc.medicines.org.uk/ (Date accessed: 03/11/2017; Date of last text revision: October 2015) https://www.medicines.org.uk/emc/medicine/6566
  22. Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Adrenaline [Epinephrine] Injection BP 1 in 1000 - Hameln) http://emc.medicines.org.uk/ (Date accessed: 03/11/2017;  Date of last text revision: 16/12/2015) https://www.medicines.org.uk/emc/medicine/20909
  23. Personal Communication.  Alex Black, Medicines Information, Profile Pharma Limited (20th August 2010)
  24. Potter RW & Hatley RHM (2004).  Determination of the effect of different re-hydration solutions upon the activity and osmolality of PromixinÔ. Journal of Aerosol Medicine 17: 101.
  25. Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Quinsair 240 mg nebuliser solution - Chiesi) http://emc.medicines.org.uk/ (Date accessed: 7/6/2022;  Date of last text revision: 08/21) https://www.medicines.org.uk/emc/product/7202/smpc
  26. Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Arikayce liposomal 590mg nebuliser dispersion - Insmed) http://emc.medicines.org.uk/ (Date accessed: 7/6/21;  Date of last text revision: 1/1/21) https://www.medicines.org.uk/emc/product/12067

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Approved By

LTHT Drugs and Therapeutics Committee

Document history

LHP version 1.0

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