Nebulisation

Nebulizers are medical devices that help people with breathing problems by turning liquid medicine into a mist that can be easily inhaled. Many people have misconceptions about nebulizers, which can make them hesitant to use these helpful devices.

Advantages of nebulization

Nebulisers can convert a liquid medication into a fine mist or aerosol, thereby making it directly available for inhalation.

Using a nebuliser requires minimal co-ordination for inhalation.

The jet nebulisers (these are the most commonly used nebulisers) are compatible with a variety of medication solutions.

Nebulisers can be used in infants, very old or weak patients, or those who need immediate treatment for an acute condition

Works in patients who are unable to breathe in deeply due to a respiratory condition [low measure of inspiratory flow].

Breath-holding is not absolutely essential for efficacy.

The concentration of the medicines to be used can be adjusted [by diluting with isotonic saline] if needed.

Nebulisers have the ability to deliver larger doses compared to the other aerosol devices

What is nebulization?

It is the process of transforming liquid medications into a fine spray (aerosol) or mist, which can then be carried into the respiratory system through inhalation.

Need for good nebulization practice

Nebulisation is a common and alternative method [other methods include inhalers, oral therapy such as tablets,& intravenous therapy] of delivering medication to the lungs. It is largely used in clinical settings for the treatment of acute respiratory ailments as well as for the long-term treatment of obstructive airway diseases such as chronic obstructive pulmonary disease (COPD), asthma, cystic fibrosis and bronchiectasis.

A nebulizer converts liquid medicine [either a solution or suspension] into vapour, aerosol or a mist so that it can be inhaled by the patient and effectively delivered directly into the lungs. The main purpose of nebulisation is to allow the medication to reach the lungs quickly and effortlessly, with very little need for coordination by the patient, a common challenge seen with handheld inhalers. Hence, it is the preferred mode of medication delivery for children, elderly, and patients who cannot effectively use handheld inhalers for various reasons.

Despite its wide acceptance and application, nebulisation therapy also attracts criticism. Often, the reasons for this are lack of knowledge, and misinformation about the use of nebulisers. With the aim of spreading knowledge and promoting the correct use of nebulisation therapy, Cipla has started a public initiative called Good Nebulisation Practice or, simply, GNP.

Nebulization in children

How to make nebulisation easier for your child

Nebulisation is simple, but the complicated part can be persuading your child to undergo it. These tips will help you calm down your child (and soothe your anxiety) before and during nebulisation.

Be vigilant
Close supervision is necessary when you administer nebulisation treatment to your child.
Be positive
Children can easily gauge the emotions of their parents and respond to them. Hence, it is a must to be positive and confident about nebulisation so that your child too mirrors this outlook and nebulisation takes place easily and effectively.
Communicate with your child
If your child is old enough to understand, make an effort to talk about nebulisation and how exactly it can make his/her condition better quickly.
Distract your child
It will help to keep your child distracted with other things during the nebulisation procedure – these will keep his/her mind occupied and calm and even help you both bond further. Here are a few suggestions:
Provide a favorite toy to play with
Narrate an interesting story
Play some engaging cartoons or a video game
Play or hum a favorite song for a relaxing effect
Nebulize in the right position
Some children prefer to sit upright on a chair, whereas others prefer to nestle in their parent’s arms. Children should always be held or made to sit upright while nebulising to give good results. The right position can simplify and ease the process of nebulisation.
Avoid nebulizing when your child is asleep or lying down
There is a risk that the medicine will not reach the lungs if you try to perform nebulisation on your child while sleeping as his/her mouth will be closed. When the child is asleep, the breathing is shallow and through the nose, which decreases the efficiency of nebulisation. There is also a chance that the child will get traumatised on being rudely woken with a mask on his/her face.
Get rid of the fear of the mask
Small children may feel that they will not be able to breathe through the face mask and revolt against wearing it.
Show them pictures of divers and snorkellers to remove this fear.
Tell your child that he/she is a superhero and needs to wear a face mask
Demonstrate by wearing the face mask yourself. You can stick pictures of your child’s favourite cartoon character on the face mask to make it seem less fearful.
Use the power of touch
Touch therapy can be one of the most calming things and envelops your child with a feeling of protection. Hold your child in your arms or hold the child’s hand during nebulisation, if need be. Pat or caress your child during the nebulisation process to show encouragement and provide reassurance.
Appreciate your child
After the nebulisation is over, give your child lots of appreciation, praise and hugs for participating in the procedure. This type of positive reinforcement is necessary to remove any fear or discomfort about nebulisation.

Pressurized metered-dose inhalers (pMDIs)

This is the most commonly used inhaler which consists of a pressurized canister that contains medication mixed with aerosol propellants that are released as a spray with the press of a button. Chances are when you think of asthma inhalers, the device you picture is a metered-dose inhaler. Metered-dose inhalers are also commonly referred to as an inhaler pump or asthma pumps since they act just like a pump. So, if you hear someone talking about inhaler pumps or a pump for asthma, you should know that they are most likely talking about the metered-dose inhaler.

While simple in nature, a metered-dose inhaler requires some coordination of actuation and inhalation (hand with breath) which can be difficult to perform for most people who use it across all age groups and especially with kids and the elderly. If there is poor coordination, the proper dose of the medication may not reach the lungs and instead, a larger proportion of the medication might get deposited in the mouth or throat, which can lead to fungal infections. This is also why doctors recommend rinsing your mouth after using inhalers. This challenge of coordination can be overcome by using a spacer.

A spacer, which is a tube-like device that is attached to the inhaler where medication can be sprayed into. Spacers are generally recommended to make the use of metered-dose inhalers easier and more effective to use so the medication can be inhaled properly without much of the dose going to waste. When it comes to an inhaler with spacer, the need for coordination reduces as there is more time to inhale the medication and receive the proper dosage.

Dry powder inhalers

Dry powder inhalers are quite different from metered-dose inhalers in the way they deliver the medication. Instead of the medication being an aerosol, these inhalers contain the medicine in a dry powder form which can be inhaled. If you are wondering why dry powder inhalers were designed, this was because of the coordination issues mentioned for metered-dose inhalers. They also gained attention when popular aerosol propellants CFCs were banned for environmental reasons as many metered-dose inhalers at the time still used them to deliver the spray (MDIs have now switched to another propellant called HFAs). Dry powder inhalers themselves can be of many types. These include DPIs that deliver a single dose, multi-dose or contain a reservoir-type system that stores the dry powder in bulk.

However, dry powder inhalers have their own advantages and limitations. Their advantages include being easier to use and being environmentally friendly. But since the formulation comes in a dry powder form, it is prone to contamination and damage in humid conditions or if there is a large change in temperature leading to a lesser dosage of medication being delivered.

Breath-actuated inhalers (BAIs)

Breath-actuated inhaler refers to inhalers that can release the medication when you breathe in. Breath-actuated metered-dose inhalers combine the benefits of MDIs like the compactness, portability, and the ability to have multiple doses while overcoming the major disadvantage of pMDIs, the need for coordination. Once ready for use, you can simply breathe in and the breath-actuated metered-dose inhaler will release the medication. Among all the types of inhalers for asthma, studies have found this one to be easier to use both in hospital settings and by patients on their own.

While it has its advantages, the breath-actuated inhalers do have their limitations too. Since they are activated by inhaling, if the force of inhalation isn’t strong enough, which can be the case for some people with breathing conditions, the medication isn’t released. BAIs can be used with a minimal inspiratory flow (force of inhalation) of around 23-35 L/min, making them suitable for use across all age groups including children and the elderly.

Nebulization tips during travel

Living with respiratory disease can often be challenging and overwhelming as it can pose certain restrictions on activities such as travelling. For some patients, using nebulisers while travelling can become cumbersome. Travelling should be done after a check-up, consultation and approval from your doctor. With the availability of portable, sleek and lightweight nebulisers, , travelling can be easier; however, the type of portable nebuliser to buy should be based only on your doctor’s recommendation.

The following tips can help you plan your journey if you have to travel with a nebuliser:

Before travelling, check if you have packed all the parts of the nebuliser kit – for example, in case of a jet nebuliser, check whether you have packed the compressor, tubing, medication cup/cap, face mask/mouthpiece and one nebuliser filter.

Pack the nebuliser kit in bubble wrap to avoid breakage or damage.

If you have been advised to use a portable, lightweight nebuliser, ensure that you carry it safely in a pouch or as per the manufacturer’s storage instructions.

Preferably, carry a portable nebuliser that can be plugged into a car’s accessory power outlet or a power bank (depends on the make of the nebuliser).

Carry additional batteries for the nebuliser in case of loss or damage.

Take an adapter if you are travelling to a different country.

Carry enough quantity of all the necessary medicines for nebulisation that have been recommended by your doctor.

Keep rescue medicines(inhalers with spacers) handy.

During air travel, check whether the airline you will be flying with allows a nebuliser to be carried/used on board.

Go for a check-up before travelling to assess your or your patient’s (if you are a caregiver) present condition and adjust the medication dosage, especially in chronic cases.

Ensure that you clean and disinfect the nebuliser kit even when you are travelling.

References

J. COPD 2012; 9:58–72, Nursing Standard 25(31): 50-56, Int J Pharm Sci & Res 2019; 10(8): 3575-82. doi: 10.13040/IJPSR.0975-8232.10(8).3575-82