Nebuliser

Nebulisers are electronic devices that turn liquids into an aerosol that can be breathed into the lungs to manage a range of respiratory conditions. Air or oxygen (depending on the patient’s condition) is bubbled through a solution of the drug to create a mist of optimum particle size to penetrate into the lower airways (about one-tenth of the diameter of a human hair). Nebulisers can vary in their efficiency, measured by their respirable drug delivery rate (PARI, 2023).

Nebulisers can be used both in clinical settings and in the home.
Various medicines can be delivered via nebuliser, including:

• saline - to help to reduce the thickness of phlegm, so it is easier to cough it out, for example in people with bronchiectasis
• antibiotics - for example, for those with cystic fibrosis
• bronchodilators and steroids - for example, for people with asthma and chronic obstructive pulmonary disease (Asthma and Lung UK, 2023)

Nebulisers can be administered in the following situations:

• routine care
• palliative care
• urgent exacerbations

Nebulised medication is delivered at a high dose, increasing the risks of side effects. A pressurised metered dose inhaler via a spacer with a mask or mouthpiece is preferred, except for life-threatening exacerbations. Treatment with a metered dose inhaler and a spacer is as effective as a nebuliser and has the advantage of being cheaper and requiring a smaller dose to be effective (Global Initiative for Asthma (GINA), 2022).

Nebulisers are used for patients with distressing or disabling breathlessness that is not controlled by the maximum dose of medication via inhalers and spacers or when the patients are too ill or otherwise unable to use hand-held inhalers (National Institute for Health and Care Excellence (NICE), 2019).

Nebuliser therapy should not be commenced without patients being assessed by a trained respiratory clinician. This ensures that:

• nebulisers are

Nebulised solutions can be delivered by:

• attaching the mask/mouthpiece, nebuliser chamber and tubing to cylinders or piped air or oxygen (usually in clinical settings)
• via a portable, mains powered nebuliser device (usually in domestic settings)

There are different types of technology used in nebulisers to turn the nebuliser solution into an aerosol:

• jet - uses a jet of air, driven by a compressor
• ultrasonic - uses ultrasonic wave technology
• mesh - the vibrating mesh pulls the drug through microscopic holes in the mesh

People can purchase their own nebulisers to use at home after being assessed by a trained respiratory clinician, who will be able to recommend the right device and teach the person and/or carer how to use it.

The clinician should offer people a choice between a face mask, mouthpiece or tracheostomy mask to administer their nebulised therapy. Masks need to be an appropriate size and close fitting.

1. Explain the procedure to the person and obtain informed consent
2. Check the prescription chart and choose the appropriate medication, dose and frequency
3. Check for any allergies, such as latex, in which case use latex free masks and mouthpieces
4. Refer to manufacturer instructions if unfamiliar with the device
5. Wash and dry hands
6. Position the patient appropriately according to their condition (in a conscious person, sat upright, chin level with the ground, to open the airways)
7. Encourage the person to breathe in a normal, relaxed way
8. Unscrew or flip open the top of the nebuliser chamber
9. Place the nebuliser solution in the chamber
10. Close the top, ensuring the chamber is kept upright to avoid spilling contents
11. Attach the oxygen/air tubing to the bottom of the chamber and connect the other end of the tubing to the oxygen/air source (piped, cylinder or portable nebuliser)
12. Set the oxygen/air flow rate to the number of

• As with all electrical equipment, electrically powered devices such as compressors must not come in contact with water or other liquid while connected to the mains electricity
• Do not use or store nebulisers in a room that is very dusty or very smoky
• When using the nebuliser, place it on a clean, flat table surface – do not use it on a carpet or rug, as fibres could be drawn into the nebuliser whilst in use
• Keep all parts of the nebuliser (including the tubing) away from children and pets
• Do not try to modify the nebuliser and do not cover the air intake grills on the nebuliser machine
• Not all nebuliser systems have been found to be efficient (Medicines and Healthcare products Regulatory Agency, 2018) Devices should be CE marked (indicating that they comply with the relevant EU legislation)
• Nebulisers should be serviced regularly as per the manufacturers’ instructions.

Use of nebulised therapy should be reviewed after an appropriate period by the prescribing clinician to confirm that one or more of the following occurs:

• a reduction in symptoms
• an increase in the ability to undertake activities of daily living
• an increase in exercise capacity
• an improvement in lung function (NICE, 2019)

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 2: Procedures for the planning, provision and management of person-centred nursing care

11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation

11.1 carry out initial and continued assessments of people receiving care and their ability to self-administer their own medications

11.2 recognise the various procedural routes under which medicines can be prescribed, supplied, dispensed and administered; and the laws, policies, regulations and guidance that underpin them

Asthma and Lung UK. Using a nebuliser at home. 2023. https://www.asthma.org.uk/advice/severe-asthma/treating-severe-asthma/using-a-nebuliser/ (accessed 20 December 2023)

Global Initiative for Asthma (GINA). GINA report, global strategy for asthma management and prevention. 2022. https://ginasthma.org/gina-reports/ (accessed 20 December 2023)

Global Initiative for Asthma (GINA). Difficult to treat and severe asthma in adolescents and adult patients: diagnosis and management. 2023a. https://ginasthma.org/wp-content/uploads/2023/09/GINA-Severe-Asthma-Guide-2023-WEB-WMS.pdf (accessed 20 December 2023)

Global Initiative for Asthma (GINA). Pocket guide for asthma management and prevention. 2023b. https://ginasthma.org/wp-content/uploads/2023/07/GINA-2023-Pocket-Guide-WMS.pdf (accessed 20 December 2023)

Medicines and Healthcare products Regulatory Agency. Aquilon series of nebulisers – CE mark withdrawn and supply ceased (MDA/2018/008). 2018. https://www.gov.uk/drug-device-alerts/aquilon-series-of-nebulisers-ce-mark-withdrawn-and-supply-ceased (accessed 20 December 2023)

National Institute for Health and Care Excellence (NICE). Chronic obstructive pulmonary disease in over 16s: diagnosis and management. 2019. https://www.nice.org.uk/guidance/ng115/chapter/Recommendations#managing-stable-copd (accessed 20 December 2023)

National Institute for Health and Care Excellence (NICE). Chronic obstructive pulmonary disease: muscarinic antagonists. 2023. https://cks.nice.org.uk/topics/chronic-obstructive-pulmonary-disease/prescribing-information/muscarinic-antagonists/ (accessed 20 December 2023)

PARI. What makes an efficient nebuliser system? 2023.