Trust Guideline

NEBULISER GUIDELINES
All healthcare professionals must exercise their own professional judgement when
using guidelines. However any decision to vary from the guideline should be
documented in the patient records to include the reason for variance and the
subsequent action taken.

Lead Clinician(s): Helen Designation Specialist Respiratory Nurse-

Abdullah COPD
Lead Director Sandra Rote

Ratified by: Quality and Safety Committee

Date of Ratification 29th January 2008

This Policy should not be used after end of: January 2010

Links into Healthcare Standard:

Impact Analysis (Race Equality)

Impact Analysis (Mental Capacity Act)

CONTRIBUTION LIST

Key individuals involved in developing the document

Name Designation
Helen Abdullah Specialist Respiratory Nurse - COPD
Vicky Preece Associate Director of Nursing

Circulated to the following individuals for comments

Name Designation
Sue Lunec PCT Pharmacist
Maria Wilday Matron/Manager POWCH
Carole Clive Infection Control Nurse
Melanie Hart PPF Practice Nursing/Community Matron
Alison Glover District Nurse
Gladys Davies District Nurse
Cathy McCleod Community Physiotherapist
Nigel Window Specialist Respiratory Nurse
Sue Bosworth Primary Care Services Development
Manager
Lesley Way Patient Safety Manager

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Contents

1.0 Introduction ....................................................................................................... 4

2.0 Scope of Guidelines .......................................................................................... 4
3.0 Competency Required ...................................................................................... 5
4.0 Responsibility and Accountability ...................................................................... 5
5.0 Patients Covered .............................................................................................. 5
6.0 Hazards / Complications ................................................................................... 5
7.0 The Procedure .................................................................................................. 6
8.0 Special Precautions .......................................................................................... 7
9.0 Delivery Gas ..................................................................................................... 8
10.0 Residual Volume ............................................................................................. 9
11.0 Fill Volume ...................................................................................................... 9
12.0 Nebulisation Time ........................................................................................... 9
13.0 Infection Control Issues................................................................................... 9
14.0 Storage ......................................................................................................... 10
15.0 Safety............................................................................................................ 10
References............................................................................................................ 10
BIBLIOGRAPHY ................................................................................................... 11

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1.0 Introduction

“The aim of nebuliser treatment is to deliver a therapeutic dose of the drug as an

aerosol in the form of respirable particles within a fairly short period of time” (British
Thoracic Society 1997 (B T S), Currie & Douglas 2007)

“Nebulisers are useful when large doses of inhaled drugs are needed when patients
are too ill or otherwise unable to use handheld inhalers and when drugs are not
available in that format for example antibiotics” (B T S 1997)

The commonest indication for nebulised therapy is the emergency treatment of acute
asthma and exacerbations of chronic obstructive pulmonary disease. However it can
also be used long term to deliver regular higher doses of bronchodilators that have
shown to be beneficial in some patients. Nebuliser therapy is also indicated to deliver
prophylactic medication such as steroids for patients unable to use other inhalation
devices (particularly a young child), to deliver antibiotics such as colistin in cystic
fibrosis, and budesonide for a child with sever croup.

Please note nebulisers and compressors are not available on the NHS.

2.0 Scope of Guidelines

These guidelines cover all staff working on behalf of Worcestershire Primary Care
Trust who administer nebulised therapy.

The purpose of these guidelines is to:

Provide a framework for standardised nebuliser administration.

Provide healthcare professionals with support, knowledge and evidence of good
practice necessary for them to safely administer nebulised therapies.

These guidelines cross reference with:

• The PCT’s Medicine Policy
• The Worcestershire Support Services Agency Infection Control
Policy and Procedures

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3.0 Competency Required

These guidelines apply to all healthcare professionals who undertake administration

of nebulised therapies. Nebulised medications must be administered in accordance
with the Worcestershire PCT Trust Medicines Policy.

4.0 Responsibility and Accountability

All healthcare professionals who administer nebulised therapies should be aware of

the contents of these guidelines. They are reminded that they should at all times
adhere to:
• The Nursing and Midwifery Council Code of Professional Conduct (2002)
• The Chartered Society of Physiotherapists’ Rules of Professional Conduct
(2002)
NB. The Trust’s Medicines Policy supports the health care assistants working in the
community setting to administer nebulised medicines. However, it must be
remembered that the registered health care professional who delegates this task to a
health care assistant, is accountable for the delegated task.

5.0 Patients Covered

These guidelines apply to all patients treated as inpatients, outpatients and in their
home environments.

6.0 Hazards / Complications

Adverse side effects of nebulisation are usually considered to be drug related. These
include:
• Giddiness
• Tremor
• Nausea
• Palpitations
• Dry mouth
• Wheeziness
• Bronchospasm

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 • Constipation
• Irritable cough
These side effects are usually easily remedied and the patient can be reassured by
observing their breathing pattern and consulting the prescribing physician (Cockcroft
1989).

Nebulised solutions, which are cold, non-isotonic, acidic or contain certain

preservatives can cause bronchoconstriction. Adverse effects can be monitored by
measuring spirometry or peak flow before and after an initial dose of the drug.

Following inhalation via a facemask it is advisable to wash the face to prevent skin
irritation. It is also advisable following steroid inhalation to rinse out the mouth to
avoid possible oral candidiasis (Dodd 1996).

7.0 The Procedure

• The patient should be sat in a comfortable upright position to enable the

nebuliser to function optimally.
• Medications should be given in accordance with the prescription or Patient
Group Direction (PGD) via the nebuliser chamber.
• The appropriate equipment for delivery of the nebulised therapy should be
collected on a clean surface.
• The compressor should be placed on a hard safe surface (not the floor) when
in use.
• The driving gas (hospital use) should be set at the appropriate flow rate.
• Patients should be advised to relax and breathe normally
• The treatment is nearly finished when the nebuliser begins to “spit”. At this
point the patient or carer should gently tap the side of the nebuliser a few
times. The next time the nebuliser begins to “spit” the treatment is complete.
• Once the nebuliser is complete the driving gas or compressor should be
switched off.
• The nebuliser should either be disposed of or cleaned in the recommended
manner. (see section 13.0) (Jevon 2007)

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8.0 Special Precautions

• Mask or Mouthpiece
Bronchodilator responses are the same whether a mask or mouthpiece is used. The
choice should therefore depend upon patient preference and convenience.
Facemasks should be tight fitting and patients should be advised to breathe with an
open mouth (B T S 1997)

• Ipratroprium Bromide
The health care professional must be aware that there is a potential risk of glaucoma
if ipratroprium bromide (especially when mixed with salbutamol) comes into contact
with the eyes. Wherever possible a mouthpiece should be used in preference to a
facemask. Where the patient is too ill to cope with a mouthpiece eye protection e.g.
glasses or goggles should be provided (Dodd 1996). Anti-cholinergic bronchodilators
must also be used with caution in patients with benign prostatic hyperplasia and
bladder outflow obstruction (B N F 2007)

• Antibiotics
When nebulising antibiotics the nebuliser set should be fitted with a filter system.
Filters should be allowed to dry thoroughly between uses. If nebulising at home,
patients may nebulise antibiotics alone in a separate room with an open window and
closed door without using a filter system. However the use of a venting system or
filter is preferable (B T S 1997). A mouthpiece should also be used to prevent topical
deposition on the skin.

• Steroids
The special precautions used for nebulised antibiotics also apply to nebulised
steroids. One further precaution is the prevention of oral candidiasis. Therefore it is
advocated that the patient rinses their mouth out or cleans their teeth following
nebulisation.

• Other Drugs
Where nebulisation of other drugs is considered e.g. lignocaine, advice from the
pharmacist or respiratory team should be sought.

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 • Dosage
The proportion of a nebuliser solution that reaches the lungs can be as high as 30%
but more frequently is close to 10% or less. Consequently the dose of a
bronchodilator given by nebulisation is much higher than by inhaler. Patients should
be advised of this.

9.0 Delivery Gas

A gas flow of 6 – 8 litres per minute is required for jet nebulisers to provide 50% of
the particles at a diameter of less than 5 microns. This is the size required for
adequate deposition in the distal airways. Compressed air (via piped system in
hospital) or compressor (in hospital or community) is the most commonly used driving
gas. (Esmond 2001).

Hospital use- Piped oxygen can be used for patients suffering with acute asthma at
a rate of 6 – 8 litres per minute unless otherwise stated on the packaging of the
nebuliser equipment being used.

Community use- Most domiciliary oxygen cylinders are only capable of delivering 4
litres per minute and are inappropriate for driving nebulised medications (Evans
1990), therefore an electrical compressor is required. The home oxygen contractor
can supply cylinders that deliver greater flow rates via a multi-flow valve. These are
normally supplied in consultation with the home oxygen contractor and an additional
home oxygen order should be completed. However, it is preferable that patients have
air driven nebulisers and are given supplementary oxygen concurrently by nasal
cannulae, if required.

Air should always be used where there is a risk of carbon dioxide retention by
patients with chronic obstructive airways disease. (Esmond 2001)

In accordance with the PCT Medicine Policy the driving gas must be specified as part
of the prescription.

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10.0 Residual Volume

This is the volume of the solution left in the chamber when nebulisation is complete.
It is important to know this volume, since the fill volume required for drug delivery can
then be determined. Most nebulisers have a residual volume of 0.5 – 2.5 ml. Low
residual volumes allow a smaller fill volume. (Esmond 2001)

11.0 Fill Volume

In order to maximise the efficiency of the nebuliser, the drug chamber must be filled
with a minimum volume of drug to enable a sufficient dose to be given. Most
chambers require 2 – 4.5 ml depending on the residual volume. For residual
volumes of less than 1 ml, the fill volume need not be more than 2.5 ml. For residual
volumes of more than 1 ml, a fill volume of at least 4 ml is required. (Esmond 2001)

12.0 Nebulisation Time

For bronchodilators, nebulisation time should be 5 – 10 minutes. Longer nebulisation

time will decrease patient adherence to treatment (Smith 1986). Other drugs may
require a longer time for nebulisation to be completed in order to achieve a higher
drug output. Tapping the nebuliser towards the end of the nebulisation time has
shown to increase the total volume of drug nebulised. (Everard et al 1994)

13.0 Infection Control Issues

Bacterial contamination is a frequent finding in compressors and may be the source

of pathogens. (Barnes 1987)

All nebuliser administration sets are single patient use only.

Nebuliser masks, mouthpieces and tubing can be re-used for the same patient
unless specifically stated on the packaging. All administration equipment except the
tubing should be washed after each use with general purpose detergent and warm
water. They should then be thoroughly dried using a soft towel. The tubing should
be attached to the gas delivery device and turned on for a few seconds, which will
remove any dampness from inside the tubing. Ensure all the equipment is dry before

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putting it in a designated container ready for its next use. For hospital patients this
container should be clearly labelled with the patient’s name.
The compressor when unplugged will need to be wiped over with a damp cloth and
general-purpose detergent. This procedure needs to be carried out weekly.

14.0 Storage

When not in use the compressor should be stored clean and dry without nebuliser
equipment attached.

15.0 Safety

It is a legal requirement that compressors have an electrical safety check at regular

intervals, the frequency of which is determined at local level. Records of the dates of
safety checks of compressors and detachable leads are mandatory (DOH 1991).

References

BARNES K L, ROLLO C, HOLGATE S T, MURPHY D, COMBER P, BELL E, (1987):

Bacterial contamination of home nebulisers: British Medical Journal: 295: pp 812

BRITISH NATIONAL FORMULARY (2007): No 54 September 2007: Pharmaceutical

Press: Oxon

BRITISH THORACIC SOCIETY (1997): Nebuliser Therapy Guidelines: Thorax: 52

suppl 2: S4 – 24

CHARTERED SOCIETY OF PHYSIOTHERAPISTS (2002): Rules of Professional

Conduct

COCKCROFT D W, HURST T S, GORE B P, (1989): Importance of evaporative

water losses during standardised nebulised inhalation provocation tests: Chest: 96
pp 505 – 508

CURRIE G, DOUGLAS J (2007): Oxygen and inhalers, in: Currie G (ed) ABC of
COPD: Oxford: Blackwell

DEPARTMENT OF HEALTH (1991): Safety of electrical medical and laboratory

equipment: Safety Action Bulletin No. 74: SAB (91): 57: Department of Health:
London

DODD M, (1996): Nebuliser therapy: what nurses patients need to know: Nursing
Standard: 10 (31): April: pp 39 - 42

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ESMOND G, (2001): Respiratory Nursing: Bailliere Tindall: London

EVANS D H, (1990): Dangers of Nebulisers: Lancet: 6 pp 336

EVERARD M L, EVANS M, MILNER A D, (1994): Is tapping jet nebulisers

worthwhile?: Archives of Diseases in Childhood: 70 pp 538 – 539

JEAVON P, (2007): Respiratory Procedures part 3 use of a nebuliser: Nursing Times

vol103 No 34 Aug 21 pp 24-25

NURSING AND MIDWIFERY COUNCIL (2004): the NMC Code of professional

conduct: standards for conduct, performance and ethics.

WORCESTERSHIRE PRIMARY CARE TRUST MEDICINE POLICY ( 2007 )

SMITH G, (1986): A patients view of cystic fibrosis: Journal of Adolescent Health

Care: 7 pp134 – 138

BIBLIOGRAPHY

WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST (2002): The Clinical

Guideline for the use of Nebulisers: WHAT-RES-002

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