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Nebulised Drugs Guide For Adults

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					                                                Nebulised Drugs Guide In Adults

General indications for nebuliser treatment:
 Need for large drug dose
 Patient incapable of managing hand held inhalers
 Drug delivery to the alveoli required
 Drug unavailable in an inhaler


Types of Nebulisers:
 Jet: the aerosol is generated by a flow of gas (either air or oxygen) from an electrical compressor or an oxygen cylinder. At least 50% of
    the aerosol produced at the recommended driving gas flow should be particles small enough to inhale; usual type used on the wards for
    drug administration
    Examples: Ventstream®, Sidestream®, Pari LC®
 Ultrasonic: an electrically driven system that generate aerosol by ultrasonic vibrations of a piezo-electric crystal on the drug solution,
    therefore do not require a gas flow; usually used by physiotherapist for sputum induction.
 Mesh: a new technology which converts liquid to aerosol by a vibrating mesh. Examples: Pari e-flow and I-neb


Equipment:
   Facemask can be used for bronchodilators, particularly in patients who are acutely ill or fatigued, regardless of the nature of the drug.
   Mouthpiece (which can be obtained from respiratory wards / respiratory specialist nurses) should be used for other drugs (including
    anticholinergics, steroids or antibiotics) to limit environmental contamination and / or contact with the patient’s eyes. It is always
    preferable to use a mouthpiece rather than a mask if possible.
   Nebuliser chambers: separate chambers are needed for antibiotic and Dornase alpha (Pulmozyme®)
   Others: tubings, filters, exhaust tubings (contact Respiratory Specialist Nurses for advice and supply, as different nebuliser may
    require different type of filter)
Delivery Time:
   Nebulisation time is usually 5 - 10 minutes. Nebulisers cannot be run to ‘dryness’. However, owing to the viscosity of antibiotics and
    steroids, nebulising time may need to be increased. The nebuliser chamber should be tapped when spluttering occurs.
   Nebulisation time is usually between 2 – 5 minutes with the mesh nebulisers


Diluents & Fill Volumes:
Common volume of nebuliser solution is 2 – 4.5mL; Residual volume is commonly 0.5mL


Driving Gas:
   In acute asthma exacerbation, oxygen should be used to deliver bronchodilators. Patients with severe asthma are often hypoxic.
    Giving a bronchodilator via air may worsen hypoxaemia. Ideally, piped oxygen is preferred to oxygen cylinders if patients are on
    frequent nebulisation of bronchodilators.
   In all other situation (including COPD exacerbation), compressed AIR should generally be used.


Flow Rate:
Gas flow rate should be set at 6 – 8 litres /minute to produce aerosol droplets less than 5 microns (i.e. small enough for efficient drug
deposition into the bronchial tree)
1. Mucolytics - reducing sputum viscosity / loosen up secretion and aids expectoration
Drug                                         Adult Dose                                                 Comment

Acetylcysteine1                         200mg – 400mg TDS                   1 – 2mL of 20% injectable solution made up to final volume of
200mg/mL                                                                     4mL with sodium chloride 0.9%
(B,C)                                                                       Do not run the nebuliser with > 50% oxygen as it inactivates
                                                                             acetylcysteine (e.g. during ventilation)
£2.50 / 10mL amp
Dornase alfa2                                2.5mg OD                       2.5mL (undiluted) via jet nebuliser, Pari e-flow or iNeb nebuliser
                                                                             [If using iNeb (unlicensed), need to use twice – 1mL fill each
Cystic fibrosis only
                               NB: In special circumstances, dose can        time]
(A)                            be increased to 2.5mg BD only by CF          After morning physiotherapy or in late afternoon or early
                               consultants; reduce to OD as soon as          evening; leave an absolute minimum of 30min. between
                               patient improves                              inhalation and physiotherapy
                                                                            Store in its foil pouch in fridge to prevent degradation of the
                                                                             protein; avoid heat & light
                                                                            Discard if exposed to room temperature > 24 hours
                                                                            Do not use within 30 minutes of nebulised antibiotics
£18.52 / 2.5mL amp                                                          Do not use if the solution becomes cloudy or discoloured
                                                                            Do not dilute or mix with other drugs

Sodium chloride 0.9%3              5mL QDS or PRN upto 2 hourly             Also used to aid humidification
                                        (via jet nebuliser)                 Ensure nebulised salbutamol is prescribed in            case of
(B,C)                                                                        bronchospasm during sodium chloride nebulisation
                                              30mL PRN
£0.33 / 5mL amp                       (via ultrasonic nebuliser)
Hypertonic saline 7%                                                        Pre-treatment with inhaled / nebulised salbutamol to reduce the
(unlicensed preparation)                                                     risk of bronchospasm during the hypertonic saline nebulisation
(B,C)

Mucolytic / reduce sputum                   4 mL BD4,5,6                    Via jet nebuliser or Pari e-flow
viscosity in cystic fibrosis

£4.64 / 100mL bottle



 Key - A: Licensed dose/indication B: Current local practice/regime C: Unlicensed dose/indication
2. Bronchodilators – relax smooth muscles in the airway to relieve symptoms (e.g. wheeziness, bronchospasm)
Drug                                         Adult Dose                                                Comment
                                                                         (All mixtures must be visually checked for compatibility, do not give if
                                                                         solution becomes cloudy or precipitates)
Salbutamol                       2.5mg – 5mg 4 – 6 hourly or PRN;           Frequent nebulisation is often required in the treatment of acute
(A)                                Can be given up to every hour             exacerbation of asthma
£1.75 / 20 X 2.5mg                                                          Pre-physiotherapy (in CF) or pre-treatment prior to nebulised
£2.95 / 20 X 5mg                                                             antibiotics
Terbutaline                      5mg – 10mg 4 – 6 hourly or PRN;            May be mixed with ipratropium
(A)                               Can be given up to every hour             Can be diluted to 4mL with sodium chloride 0.9%

£4.04 / 20 X 5mg
Ipratropium                       250mcg – 500mcg 4 – 6 hourly              Use of mouthpiece preferable (particularly in patient with
(A)                               Max. daily dose: 500mcg QDS                glaucoma)
                                                                            Can be diluted to 4mL with sodium chloride 0.9%
£0.50 / 500mcg amp                                                          May be mixed with salbutamol or terbutaline

Combivent®        (contains           1 nebule 4 – 6 hourly                 See above
2.5mg salbutamol + 500mcg         Max. daily dose: 1 nebule QDS
ipratropium) (A)

£0.42 / amp
Adrenaline     1 in 1000                                                    May be diluted with sodium chloride 0.9% to 4mL
(1mg/mL)                                                                    Short term use only due to rebound effect
(B,C)                                                                       Observe closely with ECG and monitor oxygen saturation

Stridor                          1mg (1mL) STAT repeat every 30
                                         minutes if required
                                (effect usually lasts for 2 – 3 hours)

Laryngeal oedema or croup      2 – 5mg (2 – 5mL) PRN 2 hourly (Max.
                                 single dose is 5mg) post extubation

£0.46 / 1mL amp




 Key - A: Licensed dose/indication B: Current local practice/regime C: Unlicensed dose/indication
3. Corticosteroids – as prophylactic to suppress inflammation in asthma; issue steroid card if long term use
Drug                                         Adult Dose                                                 Comment
                                                                          (All mixtures must be visually checked for compatibility, do not give if
                                                                          solution becomes cloudy or precipitates)
Budesonide (suspension)7                  1mg – 2mg BD                       Can be mixed with sodium chloride 0.9% to make up a final
500mcg/2mL                      (Maintenance dose: 0.5mg – 1mg BD)            volume of 4mL
1mg/2mL                                                                      Compatible      with    salbutamol,    terbutaline,   ipratropium,
(A)                           via a VENTSTREAM CIRCUIT (contact               acetylcysteine
                              Respiratory Specialist Nurse for advice             - mix immediately before use
                              re. ordering)                                       - be aware that solution volume may be too large
£1.60 / 500mcg amp                                                           Use mouthpiece to prevent irritation on facial skin & eyes
£2.23 / 1mg amp                                                              Rinse mouth thoroughly with water after inhalation
                                                                             Not suitable for use via ultrasonic nebuliser
                                                                             Issue a steroid card for long term use

Fluticasone (suspension)8                500mcg – 2mg BD                     May be diluted with sodium chloride 0.9% to make up a final
0.5mg/2mL                                                                     volume of 4mL
2mg/2mL                                                                      Avoid mixing with other drug solutions as lack of compatibility
Non-formulary                 via a VENTSTREAM CIRCUIT (contact               data
(A)                           Respiratory Specialist Nurse for advice        Use mouthpiece to prevent irritation on facial skin & eyes
                              re. ordering)                                  Rinse mouth thoroughly with water after inhalation
NB: 100mcg of fluticasone ≡                                                  Not suitable for use via ultrasonic nebuliser
200mcg of beclomethasone /
budesonide                                                                   Issue a steroid card for long term use

£0.93 / 500mcg amp
£3.73 / 2mg amp




 Key - A: Licensed dose/indication
4. Anti-infectives – as prophylaxis or treatment for bacterial / fungal / viral colonisation in the lungs
     Refer to recent sputum culture and sensitivities to guide choice of antibiotic
     Administer after inhaled / nebulised bronchodilator or physiotherapy to prevent bronchoconstriction induced by hypertonicity of the
      antibiotic solution and to maximise deposition
     Give via MOUTHPIECE
     To prevent staff sensitisation and antibiotic resistance, a one-way valve must be used either via an exhaust tubing so that exhaled
      antibiotic can be discharged via a window or a filter system (appropriate for the selected nebuliser) on the expiratory port
      (disposable filter from the Pari system should be replaced after each dose).
      Contact Respiratory Specialist Nurse for advice on the required filter system. Exhaust tubing can be obtained from Southwell or
      Respiratory Specialist Nurse.
     Pari or Ventstream nebulisers are routinely used for nebulising antibiotics
     First dose must be given in hospital and PEFR or spirometry performed before and after administration by Respiratory Specialist
      Nurse to check that the patient does not experience any problems such as bronchospasm. In some patients additional
      bronchodilators may be required before the inhaled antibiotic.

Drug                                            Adult Dose                                                  Comment

Amikacin9 (C,D)                                500mg BD                          Can be further diluted to a final volume of 4mL with sodium
(500mg/2mL injection)                                                             chloride 0.9% or water for injection
£ 10.14 / 500mg vial                                                             Do not mix with other drugs

Ceftazidime10,11 (C,D)                            1g BD                          Reconstitute each vial with 3mL of water for injection
£8.50 / 1g vial
Colomycin12                               1 million unit (MU) BD                 Dissolve each 1MU vial with 2mL of sodium chloride 0.9% or
(A)                                                                               water for injection
£1.68 / 1MU vial                             2 million units BD                  Dissolve each 2MU vial with 4mL of sodium chloride 0.9% or
£3.09 / 2MU vial
                                                                                  water for injection
Promixin®13 (A)
£4.60 / 1MU vial
                                       1 million units BD via iNeb               Dissolve each vial with 1mL of sodium chloride 0.9%
                                 (can be increased to 2 million units BD)
Gentamicin10,11 (C,D)                      80mg – 160mg BD                       Can be further diluted to a final volume of 4mL with sodium
(80mg/2mL injection)                                                              chloride 0.9%
£1.54 / 80mg amp
Meropenem9                                      250mg BD                         Dissolve each 500mg vial with 10mL of water for injection and
(C,D)                                                                             nebulised 5mL of this solution over 5 – 10 minutes
£14.33 / 500mg vial                                                              Remaining reconstituted solution can be kept in the fridge for no
NB: only for B. cepacia                                                           longer than 24 hours; alternatively fresh vial can be used for
eradication in CF                                                                 each dose


    Key - A: Licensed dose/indication B: Current local practice/regime C: Unlicensed dose/indication
          D: Restricted antibiotic – microbiology approval only, regular review required
4. Anti-infectives (continued)

Drug                                         Adult Dose                                                 Comment

Tobramycin 14                                300mg BD                        Licensed for use with the Pari LC Plus nebuliser, filters provided
(TOBI 300mg/5mL                (Alternating 28 days on and 28 days off)       by the manufacturers free of charge
preservative free nebuliser                                                  Should not be diluted or mixed with other drugs
solution ) (A)                                                               Store in fridge
                                                                             Licensed for CF only, all other indications need microbiology
£26.50 / 300mg amp                                                            approval
Ribavirin16,17                     2gram twice to three times a day     Ribavirin is classified as a ‘Substance Hazardous to Health’
Nebuliser powder 6g/vial for                                            under the COSHH regulations 1994, should only be
inhalation solution            (2 hours on and 6 hours off within a 24 administered by those experienced in its use – normally BMT
(A,B)                          hours period; treatment duration depends or adult haematology wards
                               on patient’s response and is decided by  Potentially teratogenic, women of child bearing age or who are
                               consultant)                                  breastfeeding should avoid drug contact
                                                                         The Product Insert Leaflet should be read before administration
                                          Via SPAG generator             A separate Trust’s guidelines for the safe administration of
£349 / 6g vial                                                              nebulised ribavirin must be followed
                                                                         Dissolve each vial with 100mL of water for injection and
                                                                            nebulise 33mL (2g) over 2 – 3 hours
                                                                         Reconstituted solution is stable in fridge within 24 hours
Pentamidine      isetionate                                               Pentamidine is a potentially toxic drug with many side effects
nebuliser solution 15                                                     and should only be administered by those experienced in its
(A)                                                                       use
                                                                           Caution in patients at high risk of pneumothorax
Treatment of Pneumocystis              600mg OD for 3 weeks                Respirgard II (trade mark of Marquest Medical Products inc.),
carinii pneumonia (PCP)                                                      modified Acorn system 22 (trade mark of Medic-Aid) or an
[usually in patient infected                                                 equivalent device with either a compressor or piped oxygen at a
with HIV]                                                                    flow rate of 6 to 10 litres/minute
                                                                           A standard 0.3 micron microbiological filter can be fitted to the
Prevention of PCP                      300mg once a month or                 exhaust vent of the nebuliser
                                       150mg every two weeks               Any solid material evident in the polyethylene bottle should be
                                                                             re-dissolved by gentle warming in the hand before use
£32.15 / 300mg bottle                                                      protective clothing (mask, goggles, gloves) must be worn by
                                                                             staff administering pentamidine
                                                                           should be given in a vacated well ventilated room, ideally in a
                                                                             side room away from the main ward area


  Key - A: Licensed dose/indication B: Current local practice/regime C: Unlicensed dose/indication
        D: Restricted antibiotic – microbiology approval only, regular review required
5. Local Anaesthetics: Management of chronic cough, which has failed to respond to other treatments – palliative care
Drug                                             Adult Dose                                                   Comment

Lignocaine 2%18                            5mL    PRN up to QDS                   Risk of bronchospasm; a bronchodilator should be nebulised
(C)                                                                                prior to nebulising local anaesthetic
                                                                                  Fast for 1 hour after nebulisation due to the reduced sensitivity
£0.25 / 5mL amp                                                                    of the cough reflex; may increase risk of aspiration
Bupivacaine 0.25%18                        5mL    PRN up to TDS
(C)

£1.06 / 10mL Polyamp®

Key - A: Licensed dose/indication B: Current local practice/regime C: Unlicensed dose/indication


Reference:
Unless stated, all data reproduced in this document has been obtained from
 BTS guidelines on current best practice for nebuliser treatment. Thorax 1997; 52 (Suppl 2): 1 – 106
 Nottingham City Hospital / Queen’s Medical Centre / Rushcliffe PCT Nursing Practice Guidelines – Adult Nebuliser Guidelines 2005

   1.    Martindale: The Complete Drug Reference (2007) The Pharmaceutical Press. (www.medicinescomplete.com accessed on 29 April 2007)
   2.    Summary of Product Characteristics for Pulmozyme (www.medicines.org.uk accessed on 11/5/2007)
   3.    NCH Saline Nebuliser Guideline for Practice (review January 2008) Physiotherapy Department
   4.    Enderby et al. Hypertonic saline inhalation in cystic fibrosis – salt in the wound, or sweet success? Archives of Disease in Childhood
         2007;92:195-196
   5.    Elkins MR, Robinson M, Rose BR. et al; National Hypertonic Saline in Cystic Fibrosis (NHSCF) Study Group. A controlled trial of long-term
         inhaled hypertonic saline in patients with cystic fibrosis. N Engl J Med 2006;354:229–40
   6.    Wark PA, McDonald V, Jones AP. Nebulised hypertonic saline for cystic fibrosis. Cochrane Database Syst Rev 2005;20:CD001506
   7.    Summary of Product Characteristics for Pulmicort Respules (www.medicines.org.uk accessed on 10/5/2007)
   8.    Summary of Product Characteristics for Flixotide Nebules (www.medicines.org.uk accessed on 10/5/2007)
   9.    Personal Communication. Royal Brompton & Harefield NHS Trust
   10.   http://www.cysticfibrosismedicine.com/ (assessed on 10/5/2007)
   11.   Ryan et al. Nebulised anti-pseudomonal antibiotics for cystic fibrosis (Review) The Cochrane Collaboration. Issue 4, 2007
   12.   Summary of Product Characteristics for Colomycin (www.medicines.org.uk accessed on 11/5/2007)
   13.   Summary of Product Characteristics for Promixin (www.medicines.org.uk accessed on 11/5/2007)
   14.   Summary of Product Characteristics for TOBI (www.medicines.org.uk accessed on 11/5/2007)
   15.   Summary of Product Characteristics for Pentacarinat Ready-To-Use Solution (www.medicines.org.uk accessed 5/10/2007)
   16.   Summary of Product Characteristics for Virazole Aerosol (www.medicines.org.uk accessed on 8/1/2008)
   17.   Guidelines for the safe administration of nebulised ribavirin Nottingham City Hospital NHS Trust (Draft)
   18.   www.palliativedrugs.com (accessed on 11/5/2007)
 (Disclaimer: This information is issued on the understanding that it is the best available from the resources at our disposal at the time of
   issue and is for guidance only. For further information, please consult the Summary of Product Characteristics or contact your ward
                                              pharmacist or the Respiratory Specialist Nurse)




Written by See Mun WONG in consultation with Fiona Haynes (senior CF physiotherapist), Holly Scothern (Lead Practice Development
Nurse for Acute Medicine), Cystic Fibrosis nurses, respiratory nurses at the City campus, Dr Soo (microbiology consultant), Annette
Clarkson (microbiology pharmacist) and Respiratory Consultants at City Campus; Accuracy checked by Dr Kevin Mortimer (SpR)




Review: May 2010

				
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