Title of Guideline (must include the word “Guideline” (not

protocol, policy, procedure etc.) N09 Administration of nebulised bronchodilators
and steroids
Contact Name and Job Title (author) Rachel Keay (PDM)
Directorate & Speciality Family Health – Nottingham Children’s Hospital
Date of submission July 2015
Date on which guideline must be reviewed (this should be one to July 2020
five years)
Explicit definition of patient group to which it applies (e.g. Children who require nebulised bronchodilators.
inclusion and exclusion criteria, diagnosis)
Abstract This guideline describes performing/caring for a
child having nebulised bronchodilators.
Key Words Nebulised, bronchodilators, children’s.
Statement of the evidence base of the guideline – has the 1, 4 and 6
guideline been peer reviewed by colleagues?

Evidence base: (1-6)
1 NICE Guidance, Royal College Guideline, SIGN
(please state which source).
2a meta-analysis of randomised controlled trials
2b at least one randomised controlled trial
3a at least one well-designed controlled study without
randomisation
3b at least one other type of well-designed quasi-
experimental study
4 well –designed non-experimental descriptive studies
(i.e. comparative / correlation and case studies)
5 expert committee reports or opinions and / or clinical
experiences of respected authorities
6 recommended best practise based on the clinical
experience of the guideline developer
Consultation Process D. Forster, C. Youle and A. Frost.
Target audience Children’s Nurses

This guideline has been registered with the trust. However,
clinical guidelines are guidelines only. The interpretation
and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using
guidelines after the review date.

N09 1

the presence of a parent or the type of medication being checked. if required Syringe and needle for drawing up the drug. however consideration should be used rather than a mask. requirements to produce aerosol action. if required Peak flow meter if the child is able to blow peak flows Selection of nebuliser kit Action Rationale 1 Select a nebuliser kit appropriate for the Aerosol delivery of the drug can be child. or to nebulised steroids such as budesonide. Pre-requisites Drugs for Nebulisation There are a variety of different drugs given by nebuliser. NOTTINGHAM CHILDREN’S HOSPITAL Nursing Guideline N09 Administration of nebulised bronchodilators and steroids Standard Statement A nebuliser is a chamber designed to convert a drug suspension or solution into a therapeutic mist for inhalation. mouthpiece (British Thoracic Society. This procedure requires a minimum of one registered children’s nurse who is able to act as a primary checker for medicines. Equipment Air compressor. N09 2 .1996). A second nurse may be required depending on the age of the child. increased to 85% by use of a mouthpiece Where possible a kit with a mouthpiece (Carter. 2014) 2 Read the information supplied by the Nebuliser kits made by different manufacturer about flow rates and drug companies may vary in their volume. If administering other medications by nebuliser the guideline appropriate to those medications should be consulted. should be given to whether the child is old enough to manage a mouthpiece or If a mask is used it should fit comfortably may be too breathless to manage a over the nose and mouth with few gaps. This guideline applies only to the use of bronchodilators such as salbutamol. oxygen or air supply (according to prescription) Single patient use nebuliser kit with mask or mouth piece Patient prescription chart Appropriate drug Normal saline for dilution. ipratropium bromide and terbutaline.

of drug error and as no syringe or needle is required reduces the risk of sharps injury. be mixed together. 1997).5mls can be used if the residual volume following the nebuliser is less than 1ml. 5 Check with pharmacy before mixing any Some drugs are incompatible and cannot drugs together in a nebuliser. salbutamol with ipratropium bromide. Webb and Swarbrick. going to the bedside. the drug may deteriorate or become contaminated if saved. the child will receive the same amount of the drug but over a longer period of time (Kendrick. Milner. A total volume of 2. Water should not be used as a diluent as it may cause bronchoconstriction (O’Callaghan.g. been checked. but may be reduced by sodium chloride. 4 The medication should be placed into the This prevents accidental administration nebuliser chamber as soon as it has by any other route. Mixing drugs is only usually recommended when mixing a beta 2 agonist with an anticholinergic e.Checking the Medication Action Rationale 1 Always use ready prepared nebules of Ready prepared nebules reduce the risk the correct drug dosage. 3 The drug should be diluted to a volume of Optimal drug delivery occurs with 4mls of 4mls wherever possible. using 0. N09 3 . 1991).9% solution. Smith & Wilson. 2 Once opened nebules should not be Nebules do not contain preservative and saved. decreasing compliance in younger If using a syringe and needle – it must be children as more time is needed to disposed of in the sharps bin prior to nebulise the drug.

Switch on the compressor or turn the The flow rate should produce a particle flow meter to an appropriate flow for the size of less than 5 microns to allow nebuliser. alternative treatment.Administration of the nebuliser Action Rationale 1. usually 8 litres per minute. If a mask is being used rather than a This reduces loss of medication through mouthpiece. Encourage the child to remain still and If it is considered essential that the child cooperate whilst the nebuliser is given should have the nebuliser and there is no by providing activities to distract. If oxygen is being used to nebulise the Oxygen may have a beneficial effect. against the child’s face at all times. uncooperative whilst the nebuliser is given. Increased droplet size may reduce Obstructions such as a dummy/ soother penetration of the medication into the should be removed. it may be restraining the child should be according necessary to hold a small child who is to local guidelines. breathe with an open mouth. Consideration should also be given to whether the patient already has an oxygen requirement. Check and record peak flows prior to the Alterations in peak expiratory flow can be administration of bronchodilators. 2008) This allows a better dose of medication to N09 4 . 2. as maximum penetration of the airways shown on the nebuliser kit instructions. drug it should be prescribed. (British Thoracic Society. Oxygen should not be stopped if there is a pre-existing oxygen requirement. particularly in the administration of bronchodilators in an acute asthma attack and will relieve hypoxia during the period of administration (Milner. experience It is inappropriate to record peak flows if nebulised drugs are unrelated to respiratory condition. smaller airways (Hess. 3. Connect the nebuliser chamber to the A smooth flow of gas is required in order mask and then to the compressor or to nebulise the drug effectively. the mask should be kept leakage. 2012). 1993). if the used to monitor the effect of the child is well enough and it is appropriate. Children with oxygen saturations below 92% should have nebuliser driven via oxygen (British Thoracic Society. 6. then any method of If this is unsuccessful. some children may be too may vary according to age and prior breathless to manage peak flows. Ability to blow an accurate peak flow However. Droplet size increases as the distance The child should be encouraged to from the chamber increases. 2014) 5. medication and the child’s progress. flowmeter using the smooth tubing provided. 4.

left Mussaffi. also aids compliance (Kendrick. If 4mls of liquid is being used then the Most of the drug within the liquid will be nebuliser should be continued for no nebulised within 10 minutes.. 2014) Nasal breathing equates to a 50% loss of nebulised drug reaching the lungs (Hess. This timing longer than 10 minutes. to air dry and all waste disposed of.. 1997). 8. respiratory Document and communicate to Doctor if effort. effect and increase in peak flow will show 30 minutes after the nebuliser has been that the medication has been effective. could cause chest infections (Blau. H. 1999). respirations. D. colour. 1996). H. be inhaled (British Thoracic Society. afterwards. a This allows the drug to have its maximum second peak flow should be recorded 15.. H. 2014). M. completed.. lips should be kept closed around a mouthpiece. B. The effectiveness of the medication will be monitored. If a mouth piece is used. N09 5 . 4 Following use the nebuliser chambers and This prevents colonisation of the face masks must be washed with soapy nebuliser chamber by skin bacteria which water at the bedside in a disposable bowl. or and ability to talk and eat... Prais. of the prescribed treatment (British This should include change in Thoracic Society. dried after washing with a paper towel. 2007) Outcome The child will receive an effective dose of nebulised medication comfortably and without becoming distressed. 2 Record the effect of the nebuliser in the This will help to monitor the effectiveness nursing records. 2008) 7. wheeze. calm during their nebuliser as a cooperative child would get a better dose of the drug (Iles et al. Czitron. 3 If a steroid nebuliser has been used the This prevents development of striae face and mouth should be cleaned (thinning of the skin) on the face. Mei Zahav. After the Nebuliser Action Rationale 1 If bronchodilators have been used. Steroids also increase the risk of oral candidiasis and can make the voice hoarse (Clarke and Rees. and Cohen. A. M. Livne. degree of agitation/consciousness the child was crying and distressed. M. Smith & Wilson. A smaller volume will require a shorter time (O’Callaghan et al 1989).

. H. A. (1991) Nebulised water as a bronchoconstriction challenge in infancy. EC.163-165 Kendrick..948-51 Authors: Rachel Keay and Jennifer Davidson July 2015 Review Date: July 2020 Ratified by: Clinical Educators Group June 2015 (LR. Livne. P. AK. M.D. SB. (1996) Choosing nebulisers for children. A. Lister.. T and Rees. A. British Thoracic Society (2014) British guideline on the management of asthma.C and Swarbrick.. Webb M. C. LB. H. Paediatric Nursing 8(8): pp. Mei Zahav. Clarke A.S. 53(6): pp. Child: Care. B.. T. S92 – S101 Milner A (1993) Childhood Asthma. SC) Signed off by: Dorothy Bean N09 6 .. (1996) Practical Management of Asthma 2nd ed. 81: pp.H..References Blau. M.. London: Martin Dunitz O’Callaghan. Aerosol Delivery devices in the treatment of Asthma. Archives of Disease in Childhood 66: pp. H. Prais. Respiratory Care.491–495. Hess. Carter. R.R. (2007). C. P. (1989) Why nebulise for more than five minutes? Archives of Childhood Disease.D. and Milner A. 52 (2): pp. Czitron. and Cohen. Health and Development. M... London: BTS.. R.15-16 Clarke. 63: pp.1270-1273 O’Callaghan. CL. London: Martin Dunitz. Microbial contamination of nebulizers in the home treatment of cystic fibrosis. Mussaffi. Archives of Diseases in Childhood. Milner A.699-725 Iles. D. and Wilson. A. (1999) Crying significantly reduces absorption of aerosolised drug in infants. (1997) Thorax. and Edmunds. (2008). 33: pp.. A. D. Smith. RSE.