Paediatric Nebuliser Guidelines and Monographs

Publication: 19/10/2016

Next review: 03/07/2023

Clinical Guideline

CURRENT

ID: 4768

Approved By: LAPC

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.

Paediatric Nebuliser Guidelines and Monographs

Summary of Guideline
Background
Equipment used throughout Children’s services
Correct use of nebulisers
Appendix 1 - Checklist for discharging a paediatric patient home on nebuliser therapy
Appendix 2 - Information for parents/carers and patients
Appendix 3 - Drug monographs

Summary of Guideline

Pertinent aspects of history and examination
Key diagnostic criteria
Investigations required
Treatment
Management

Background

How does a Nebuliser work?
Nebulisers use compressed gas (from a wall outlet, canister or compressor) to produce a fine mist of droplets containing active drug. This mist can be delivered deep into the patient’s lungs to help with the presenting condition.

Nebulisers are most beneficial when:

Large inhaled drug doses are required
Patients are too unwell, unable to take deep breaths, breath holding is not appropriate making inhalers difficult to use or they are unable to co-ordinate drug delivery
Drugs are unavailable in hand-held inhalers, e.g. antibiotics
Direct pulmonary therapy is required

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.

Therapeutic areas:
Asthma
Bronchiectasis
Immunocompromised Children
Cystic Fibrosis
Primary Ciliary Dyskinesia
Long term ventilation and tracheostomy

Equipment used throughout Children’s services

Equipment:
Nebulised therapy should be delivered by a mouthpiece whenever possible as it provides increased lung drug deposition and limits environmental contamination and/or contact with the patient’s eyes. A mask may theoretically deliver less medication to the lungs as nasal inhalation is used as opposed to mouth inhalation. Masks should only be used where a mouthpiece is inappropriate and the mask should be tight fitting. Patients should be advised to breathe with an open mouth.

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

Mask - This is attached to the nebuliser chamber. Facemasks should be reserved for patients unable to use a mouthpiece. If masks are required ensure they are fitted correctly and patients should be advised to breathe with an open mouth, preferably without a dummy.

Tracheostomy mask - Tracheostomy patients, who are self-ventilating on air, should have the nebuliser attached to a tracheostomy mask.

Tracheostomy Ventilation - 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.

Nebuliser chamber - This is attached to the oxygen point or compressor via tubing and this is where the nebuliser liquid is placed. The liquid produces a fine mist of droplets containing the active drug. This mist is then inhaled.

Different medications require different nebuliser chambers; please refer to the relevant individual drug monograph.

Commonly used nebuliser chambers

Other nebuliser chambers

Filters - In paediatrics, filters are required for nebulising antibiotics.

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 the Side stream Plus® and Pari LC Plus® nebuliser chambers. 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®)

SideStream® Plus Filters

Pari LC Plus® Filters

Compressors - These are machines that take in room air and expel it at high pressures. There are several types of compressors available:

Commonly used compressor

Portaneb® - This is a white compressor with a lift up lid. Portanebs® are suitable for antibiotics, bronchodilators, dornase alfa, corticosteroids, sodium chloride and liposomal amphotericin.

Innospire Deluxe® - Portanebs® are being discontinued and are being replaced by this compressor. They are suitable for antibiotics, bronchodilators, dornase alfa, corticosteroids, sodium chloride and liposomal amphotericin.

Other types of compressors that are specific for cystic fibrosis and respiratory patients

Ombra® - This is a white compressor. Ombras® are suitable for Tobi® (used with a Pari LC Plus®) and for patients with primary ciliary dyskinesia.

e-Flow® - This is a blue portable nebuliser that enables extremely efficient delivery of medication via a vibrating, perforated membrane. The chamber requires changing every 12 months and membrane every 6 months. After each use, wash the chamber and membrane in hot soapy water, then rinse the membrane with cooled boiled water. Boil the chamber and membrane once a week for 10 minutes. After boiling, rinse the membrane in cooled boiled water.

I-neb® - This is a portable and quiet nebuliser. It is breath activated and as a result it has a reduced nebulisation time compared to conventional nebulisers. It is a complete unit. The chamber, mouth piece and membrane require changing every 6 months. After each use, wash the chamber and membrane in hot soapy water, then rinse the membrane with cooled boiled water. Boil the chamber, mouth piece and membrane once a week for 10 minutes. After boiling, rinse the membrane in cooled boiled water. For replacement parts or problems contact I-neb® customer care.

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 for ward use.
Durable Tubing for SideStream®, SideStream® plus & Pari LC plus	2150A box of 10 (requisition)
Angled mouth piece for SideStream®	1091917 (requisition)
Durable SideStream® (light blue, last 12months)	FDE037 box of 10
SideStream® chamber (royal blue)	FDE697
SideStream® mouthpiece	FDE514
SideStream® mask	FDD005
SideStream® tubing (non durable)	FDD033
SideStream® plus- mask
SideStream® plus- filters	FTC155 pack of 100
SideStream® plus- chamber and filter housing	FDE039 box of 10
SideStream® plus- filters	041B0523 (requisition)
Paediatric tracheostomy mask	FDD2275 pack 50
Nebuliser T piece set	FDE083
Pari LC plus® chamber, filter housing and filters	Come free with the drug
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

Correct use of nebulisers

Using the correct technique to admisinster a nebuliser has a dramatic effect on drug delivery, therefore the correct procedure must be followed:

Encourage the patient to sit up in bed, in a chair or carers arms. Make sure they are comfortable; aiming to ensure the best possible chest expansion is achieved.
Explain the procedure to the patient and their parent/carer and obtain verbal consent. Listen to and answer any questions that they may have to alleviate any anxiety.
Nebuliser chamber, tubing, mouthpiece and mask are for single patient use only and must be disposed of on discharge.
Place the appropriate nebuliser solution into the nebuliser chamber. A final volume of at least 2mLs is recommended. Add sodium chloride 0.9% if dilution is required. Water should not be used as it can cause bronchospasm. The maximum fill volume is 5mL.
NB. For specific drug advice please see the individual drug monographs within this guideline.
Ensure the mouthpiece is attached to the nebuliser chamber. Mouthpieces should be used in the majority of patients; exceptions are unconscious patients, patients with a tracheostomy or small children. Masks should never be used in patients with glaucoma.
Connect the nebuliser tubing to the oxygen point or compressor.
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 airways.
For severe or life threatening exacerbations of asthma in children: oxygen-driven nebulisers are preferred.
- A flow rate of 6 l/min is required to drive most nebulisers. Where oxygen cylinders are used, a high flow regulator must be fitted.
- The absence of supplemental oxygen should not prevent nebulised therapy from being administered when appropriate.
Patients receiving nebulised bronchodilators for exacerbations of asthma should receive these using oxygen as the driving gas. If piped oxygen is used it should be set at a flow rate of 6-8 litres/min.
Tracheostomy patients, who are self-ventilating, 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.
Filters should be used for patients in hospital who are being administered an antibiotic. These filters are single use only.
Switch on the nebuliser compressor or air/oxygen supply, according to individual drug monographs. The patient should place their mouth around the mouthpiece or mask over their nose and mouth, 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 volumes.
The nebuliser chamber may be tapped once or twice towards the end of treatment to release any droplets trapped in the chamber.
Any residual fluid can be an ideal medium for bacteria to grow therefore please ensure the chamber is rinsed and dried, then left to air dry.
If a corticosteroid/antibiotic is being nebulised please ensure that the child rinses their mouth or has a drink after their treatment. If using a mask, please also ensure that the child has their face wiped.

Provenance

Record:	4768
Objective:	Aims 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. Objectives To provide evidence-based recommendations for appropriate diagnosis, investigation and management of patients using a nebuliser.
Clinical condition:
Target patient group:
Target professional group(s):	Primary Care Doctors Secondary Care Doctors Pharmacists
Adapted from:

Evidence base

British Thoracic Society (1997). Nebuliser Therapy Guidelines. Thorax; 52 (Supplement 2): S4-S24.
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.
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)
Anderson SD et al (1983) Evaluation of ultrasonically nebulised solutions for proactive testing in patients with asthma. Thorax; 38: 284-291.
British Thoracic Society (2008) Guideline for emergency oxygen use in adult patients. Thorax; 63 (supplement VI): vi1-vi68.
British Thoracic Society / Scottish Intercollegiate Network (2009) British guideline on the management of asthma. Guideline No 63. Revised Edition June 09. Available at: http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline_2009.pdf
British Thoracic Society (1997) Current best practice for nebuliser treatment. Thorax. 52 (supplement 2): S1-S106.
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.
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.
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
UK Medicines Information (UKMi) (2007) Medicines Q&As: Which nebuliser solutions are compatible? (available online at www.nelm.nhs.uk; accessed 14/04/2008)
Personal Communication. Guy Oliver, Senior Medical Information Officer, Novartis (3rd January 2008)
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
Lee T et al (2005) Compatibilty and osmolality of inhaled N-acetylcysteine nebulizing solution with fenoterol and ipratropium. American Journal of Health Systems Pharmacy 62(8): 828-833
Trissel LA. Handbook on Injectable Drugs, 14th Edition (2006 online edition). American Society of Health-System Pharmacists, Bethesda, USA. Date accessed: 30/09/2008
Personal Communication. Martin Goldman, Senior Medical Advisor, Forest Laboratories Ltd (2nd January 2008)
Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Pulmozyme) http://emc.medicines.org.uk/ (Date accessed: 27/09/2010; Date of last text revision: 20/09/2010)
Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Promixin) http://emc.medicines.org.uk/ (Date accessed: 27/09/2010; Date of last text revision: 20/03/2009)
Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Amikacin 250mg/mL Injection – Hospira UK Ltd) http://emc.medicines.org.uk/ (Date accessed: 27/09/2010; Date of last text revision: 03/02/2009)
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: 27/09/2010; Date of last text revision: 20/05/2008)
Summary of Product Characteristics. Electronic Medicines Compendium. Datapharm Communications Ltd. (Tobramycin 40mg/mL Injection – Hospira UK Ltd) http://emc.medicines.org.uk/ (Date accessed: 27/09/2010; Date of last text revision: 29/01/2009)
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: 27/09/2010; Date of last text revision: 02/08/2010)
Personal Communication. Alex Black, Medicines Information, Profile Pharma Limited (20th August 2010)
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

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

LAPC

Document history

LHP version 2.0

Related information

Appendix 1 - Checklist for discharging a paediatric patient home on nebuliser therapy

Appendix 2 - Information for parents/carers and patients

What is a nebuliser compressor?

Nebuliser compressor systems are used to give a large dose of drug directly into the lungs. The nebuliser compressor system you have been loaned is designed to give a fine aerosol mist from a liquid medication. This has been prescribed by your/your child’s doctor to treat your/your child’s respiratory condition.

The system consists of three main parts:

Nebuliser chamber
Compressor
Facemask or mouthpiece

Nebuliser Chamber
A nebuliser chamber is a small chamber into which the liquid medication is put and through which the air is blown to make a fine mist for you/your child to inhale.

Compressor
The compressor is an electrical and/or battery powered air pump, which supplies pressurised air to the nebuliser chamber.

Mouth piece or facemask
The mouthpiece or facemask allows you/your child to breathe the fine medication mist. Ideally a mouthpiece should be used rather than a facemask as some medications can cause eye problems e.g. dryness, and/or aggravating glaucoma, or cataracts.

How to use the nebuliser compressor system

Place the compressor on a firm surface. Avoid putting it on the floor or bed as dusty air could be drawn into the compressor.
If the compressor works from mains electricity, connect the lead to the compressor socket and then plug into the mains supply.
Wash your hands.
Connect the nebuliser chamber to the compressor with the tubing supplied.
To fill the nebuliser, unscrew the two halves of the nebuliser chamber. Take the/twist off the top of the plastic vial of the prescribed medication and empty the medication into the bottom half of the nebuliser chamber. Replace the top half and screw the two halves back together.
Connect the mouthpiece or facemask to the top of the nebuliser chamber.
Encourage the child to sit down in an upright position. Switch on the compressor. A fine mist will come out when you/your child breathes in through the mouthpiece or facemask.
You/your child should breathe normally through your/their mouth with the occasional deep breath.
At the end of the treatment, which for most medications should take approximately 10 minutes, the nebuliser will start to splutter. Tap the side of the nebuliser chamber to ensure that all the remaining droplets are expelled, although there will probably be some remaining liquid.
Switch off the compressor and unplug from the mains.
Rinse your/your child’s mouth out and wipe your/your child’s face to remove any residual droplets.
Disconnect the nebuliser chamber from the tubing so that the chamber maybe cleaned.

Cleaning
The nebuliser chamber and mouthpiece/facemask must be kept clean and dry to stop germs growing that could cause chest infections. The residual medication left behind in the nebuliser chamber will crystallise and block the nebuliser jets if it is not cleaned.

Ideally each time the nebuliser compressor is used you should;

Disconnect the tubing from the mouthpiece or facemask and nebuliser chamber, as the tubing should not be washed.
Unscrew the nebuliser chamber and wash it along with the mouthpiece or facemask in warm soapy water (washing-up liquid).
Rinse thoroughly under warm running water.
Dry thoroughly with a clean dry cloth and air dry before they are reassembled.
Attach the tubing to the compressor (without the chamber). Switch on the compressor and allow the air to blow through the tubing to dry any condensation.
Some patients will be provided with a long lasting “durable” nebuliser chamber that can be boiled, sterilised or autoclaved as per manufacturer’s guidelines once a week. Please ask the health professional issuing the machine if you are unsure which type of nebuliser chamber you have been provided with.
Once a week, disconnect the compressor from the mains electricity and wipe the surface with a clean slightly damp cloth. Never immerse the compressor unit in water.

Replacing parts
The tubing should be changed every 6 to 8 weeks and the facemask/ mouthpiece and nebuliser chamber should be changed approximately every 12 months. Replacements can be obtained from the Equipment Pool at The Leeds General Infirmary or St James’s University Hospital which are open 24 hours a day (see contact telephone numbers below) unless otherwise informed.

Servicing and break down
The nebuliser compressor should be serviced annually. To arrange for the nebuliser to be serviced please contact the Equipment pool at The Leeds General Infirmary or St James’s University Hospital (see contact telephone numbers below). The Equipment Pool engineers request that you thoroughly clean your nebuliser compressor prior to bringing it in for servicing.

If your nebuliser compressor breaks down, the Equipment Pool can arrange for it to be exchanged. We request that you telephone the Equipment Pool first and if you are able please arrange for the faulty compressor to be brought to us, but if this is not possible we will send out a replacement by car (Leeds area only).

Contact Details
24 hours a day every day

The Equipment Pool at the Leeds General Infirmary
A Floor, Jubilee Wing
Tel: 0113 3923324
The Equipment Pool St James’s University Hospital
Level 01, Gledhow Wing
Tel: 0113 2064456

Appendix 3 - Drug monographs

ADRENALINE
Mode of action	Used for haemoptysis or stridor due to airway inflammation
Dosage	All ages: 400 micrograms/kg (max 5mg) repeated after 30 minutes if necessary. The dose can be diluted with sodium chloride 0.9%¹.
Strengths available	Adrenaline 1 in 1000 must be used (1mg/ml)¹
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 The effects of the nebulised adrenaline last for 2-3 hours and the child needs to be carefully monitored for recurrence of the obstruction¹.
References	1. BNF-C 2013/14
Links	http://www.leedsformulary.nhs.uk/searchresults.asp?SearchVar=ADRENALINE&Submit=Search

AMIKACIN
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	Child 2 years and above: 250-500mg 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.
Flow rate	6-8 litres/min
Filter needed?	Yes
Compatibility	See compatibility chart
Monitoring	Lung function pre and post initial test dose
Notes	Patients should have an initial supervised test dose with pre and post dose monitoring of lung function. If needed, the patient can 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 receiving routine physiotherapy should be given nebulised antibiotics after chest clearance.
References	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 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	http://www.leedsformulary.nhs.uk/searchresults.asp?SearchVar=AMIKACIN&Submit=Search

AmBisome® (nebulised amphotericin)
Mode of action	An antifungal used for the treatment of allergic bronchopulmonary aspergillosis (ABPA).
Dosage	Child 2 years and above: 25mg twice daily for 10 days
Strengths available	50mg vial, for injection
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
Notes	Patients should have an initial supervised test dose with pre and post dose monitoring of lung function. Each 50mg vial of AmBisome® should be prepared with 12mLs water for injection and 6mLs used to nebulise. Do not use sodium chloride to prepare the solution as it will cause precipitation. A nebulised bronchodilator can/should be administered prior to administration if the AmBisome® causes bronchoconstriction. Patients receiving routine physiotherapy should be given nebulised antifungals after chest clearance. For outpatients only: Store any prepared solution in a refrigerator for a maximum of 24hours. This enables a second dose to be withdrawn from the vial. On the ward, the vial should be discarded after the first dose is withdrawn. This can be prepared by aseptics if required.
References	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	http://www.leedsformulary.nhs.uk/searchresults.asp?SearchVar=amphotericin&Submit=Search

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	Child 6 years and older: 75mg three times a day. Unlicensed under six year of age.
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
Flow rate	N/A
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 receiving routine physiotherapy should be given nebulised antibiotics after chest clearance.
References	-
Links	http://www.medicines.org.uk/EMC/medicine/22358/SPC/Cayston+75+mg+powder+and+solvent+for+nebuliser+solution/ http://www.leedsformulary.nhs.uk/chaptersSubDetails.asp?FormularySectionID=24&SubSectionRef=24.05&SubSectionID=A100&drugmatch=4332#4332

BUDESONIDE
Mode of action	Corticosteroid - reduces inflammation in the lungs
Dosage	Croup: Child over 1 month: 2mg as a single dose or in 2 divided doses separated by 30 minutes; dose may be repeated after 12 hours if necessary. Bronchopulmonary dysplasia with spontaneous respiration: Neonate: 500 micrograms twice daily Child 1- 4 months: 500 micrograms twice daily. For severe symptoms in child body weight 2.5kg or over: 1mg 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. The face needs to be wiped if using a facemask. There is no clinical data to suggest a superiority of nebulised corticosteroids over inhaled corticosteroids. Consequently, these should only be initiated after a senior respiratory specialist review¹.
References	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 http://www.leedsformulary.nhs.uk/searchresults.asp?SearchVar=Budesonide&Submit=Search BNF-C 2013/14

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 CF/ non-CF bronchiectasis. Long-term therapy in patients with CF/non CF bronchiectasis who are chronically colonised with Pseudomonas aeruginosa.
Dosage	Child under 2 year of age: 1,000,000 units (1 Megaunit, MIU) twice a day Children over 2 years of age: 2,000,000 units (2 Megaunits, MIU) twice a day
Strengths available	2,000,000 units (2 Megaunits, MIU) injection 1,000,000 units (1 Megaunit, MIU) injection
Compatible nebuliser(s)	Use SideStream® Plus with filter attachment
Flow rate	6-8 litre/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 Hypertonic solutions of colistimethate sodium can cause bronchospasm. In order to avoid this; 1,000,000 unit dose is made up with 4mLs sodium chloride 0.9% 2,000,000 unit dose is made up with 2mLs water for injection 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 Patients receiving routine physiotherapy should be given nebulised antibiotics after chest clearance
References	Pasteur MC, Bilton D, Hill AT. British Thoracic Society guideline for non-CF bronchiectasis. Thorax 2010; 65(supply I):i1-i58.
Links	http://www.medicines.org.uk/emc/document.aspx?documentid=1590&docType=SPC AMBER LEVEL 2 CLASSIFICATION http://www.leedsformulary.nhs.uk/chaptersSubDetails.asp?FormularySectionID=5&SubSectionRef=05.01.07&SubSectionID=H100&drugmatch=1729#1729

COLISTIMETHATE SODIUM (PROMIXIN®) 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 and as long term use for chronic pulmonary Pseudomonas aeruginosa infection
Dosage	Children of all ages: 1,000,000 units (1 Megaunit) 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	Promixin® should only be prescribed when the I-Neb is the desired nebuliser. It should not be prescribed for use in a conventional nebuliser as it is more expensive than Colomycin® Patients should have an initial supervised test dose with pre and post dose monitoring of lung function Prepare the 1 Megaunit dose by adding 1mL water for injection to the vial and withdraw 1mL for nebulisation The maximum fill volume of the I-neb is only 1mL Patients receiving routine physiotherapy should be given nebulised antibiotics after chest clearance
References	-
Links	http://www.medicines.org.uk/emc/document.aspx?documentid=13495&docType=SPC AMBER LEVEL 2 CLASSIFICATION http://www.leedsformulary.nhs.uk/chaptersSubDetails.asp?FormularySectionID=5&SubSectionRef=05.01.07&SubSectionID=H100&drugmatch=1729#1729

DORNASE ALFA
Mode of action	Mucolytic agent used in the management of cystic fibrosis and chronic respiratory patients
Dosage	Child 5-18 years: 2.5mg (2500units/2.5ml) once a day.
Strengths available	2500 units(2.5mg)/2.5mL
Compatible nebuliser(s)	I-neb®, eFlow® or SideStream® Be careful with powerful compressors i.e. Turboneb®
Flow rate	6-8 litre/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	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 AMBER LEVEL 2 CLASSIFICATION http://www.leedsformulary.nhs.uk/chaptersSubDetails.asp?FormularySectionID=3&SubSectionRef=03.07&SubSectionID=B100#649 http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=427

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	Acute asthma: Child under 12 years: 250 micrograms repeated every 20-30 minutes for the first 2 hours, then every 4-6 hours as necessary Child 12-18 years: 500 micrograms every 4 - 6 hours as necessary
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	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	Whyte KF, Gould GA, Jeffrey AA et al (1991). Dose of nebulised ipratropium bromide in acute severe asthma. Respiratory Medicine; 85: 517-520 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 http://www.leedsformulary.nhs.uk/chaptersSubDetails.asp?FormularySectionID=3&SubSectionRef=03.01.02&SubSectionID=A100&drugmatch=4533#4533

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	Children over one month of age: 2.5mg (dose can be doubled for children over the age of 5 years). In severe or life threatening acute asthma, the dose can be repeated every 20-30 minutes or as necessary and the frequency reduced on improvement.
Strengths available	2.5mg/2.5mLs 5mg/5mLs
Compatible nebuliser(s)	SideStream®
Flow rate	6-8 litre/min
Filter needed?	No
Compatibility	See compatibility chart
Monitoring	Clinical response Serum potassium level 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 hospital^1,2 The adverse effects of bronchodilator therapy are pharmacologically predictable and dose-dependent
References	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. 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 http://www.leedsformulary.nhs.uk/searchresults.asp?SearchVar=SALBUTAMOL&Submit=Search

SODIUM CHLORIDE 0.9%
Mode of action	Mucolytic agent
Dosage	Children of all ages: 2.5mL-5mL when required.
Strengths available	2.5mL solution for nebulisation (Sodium chloride 0.9% for injection may also be used.)
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	http://www.leedsformulary.nhs.uk/searchresults.asp?SearchVar=SODIUM+CHLORIDE&Submit=Search

SODIUM CHLORIDE 7%, 3%
Mode of action	Mucolytic agent and also used for induced sputum sampling
Dosage	Children of all ages: 4mL up to twice daily
Strengths available	Nebusal® - 4mL plastic ampoules of 7% solution MucoClear®- 4mL plastic ampoules of 3% sodium chloride
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 If needed, this should be administered immediately before a physio session, as the effect wears off very quickly Take care selecting the correct preparation. MucoClear® 6% is also marketed.
References	-
Links	http://www.leedsformulary.nhs.uk/searchresults.asp?SearchVar=SODIUM+CHLORIDE&Submit=Search

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	Acute asthma: Repeat the doses below at 20 - 30 minute intervals as necessary Child under 5 years: 5mg Child 5-12 years: 5-10mg Child 12 - 18 years: 10mg
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 Serum 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 hospital^1,2 The adverse effects of bronchodilator therapy are pharmacologically predictable and dose-dependent
References	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. 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 http://www.leedsformulary.nhs.uk/searchresults.asp?SearchVar=TERBUTALINE&Submit=Search

TOBRAMYCIN (TOBI®, Bramitob®, Tymbrineb®)
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, inhaled tobramycin is reserved for patients who meet all three of the following criteria: 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). 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 grow P. aeruginosa resistant to colistimethate sodium.or have not achieved treatment success with colistimethate sodium
Dosage	Children over 6 months of age; 300mg twice a day, usually alternate months. Continuous therapy may be used in some patients, though rarely. For Pseudomonas aeruginosa eradication, treatment is for three months continuously.
Strengths available	TOBI® solution for nebulisation 300mg/5mL Tymbrineb® solution for nebulisation 300mg/5mL Bramitob® solution for nebulisation 300mg/4mL
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) I-neb® in exceptional circumstances and permission from Respironics. Needs a purple latched chamber, and medication needs to go through twice. Note : Filters and Pari LC plus® chambers are provided free of charge from the manufacturers of Tobi® provided they are requested when ordering Tobi®.
Flow rate	6 litres/min
Filter needed?	Yes
Compatibility	See compatibility chart
Monitoring	Clinical response Adverse reaction Can cause bronchospasm
Notes	Patients with excess secretions should be given their nebulised antibiotics after chest clearance. 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. ototoxicty or nephrotoxicity, then levels may be taken. This should be a trough level
References	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 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 AMBER LEVEL 2 CLASSIFICATION http://www.leedsformulary.nhs.uk/chaptersSubDetails.asp?FormularySectionID=5&SubSectionRef=05.01.04&SubSectionID=A100&drugmatch=1872#1872 http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?id=4963&UNLID=696310792202072132558

VANCOMYCIN
Mode of action	An antibiotic used in patients who have grown Methicillin-Resistant Staphylococcus aureus (MRSA) in sputum
Dosage	Children of all ages: 5mg/kg (max 250mg) twice a day for five days
Strengths available	500mg
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 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 10mLs water for injection, then using a syringe and needle draw up the required dose of the vancomycin solution, and make up to 4mLs with sodium chloride 0.9%. Doses of 250mg may be made with 8mLs water for injection, and 4mLs withdrawn and placed in the nebuliser chamber.
References	-
Links	http://www.leedsformulary.nhs.uk/searchresults.asp?SearchVar=VANCOMYCIN&Submit=Search

MISCELLANEOUS

Several other antibiotics, including pipercillin-tazobactam, ceftazidime, meropenem 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 they are for very specialist use via Chairman’s Action only.

Key
C-Compatible N/A-Not applicable
NC-Not compatible NI-No information on compatibility therefore should not be mixed
Numbers relate to individual references - see below
When colistimethate sodium is mixed with salbutamol it should be used immediately. After prolonged exposure, partial hydrolysis of the drug to colistin base/colistin sulphate may occur, which has a higher level of biological activity23.

Paediatric Nebuliser Guidelines and Monographs

Paediatric Nebuliser Guidelines and Monographs

Summary of Guideline

Background

Equipment used throughout Children’s services

Correct use of nebulisers

Provenance

Evidence base

Approved By

Document history

Related information

Appendix 1 - Checklist for discharging a paediatric patient home on nebuliser therapy

Appendix 2 - Information for parents/carers and patients

Appendix 3 - Drug monographs

Leeds Health Pathways