Technique Pointers

Principles of proper nebulization technique

1. Introduction

a. The most common form of nebulization is with a jet nebulizer. These directions will assume a jet nebulizer is being used.

b. There are various kinds of jet nebulizers (constant output, breath enhanced, breath actuated). Specific directions will vary somewhat depending on which one is used. The following are just general principles for proper nebulization that can be followed with any of the types of jet nebulizers.

2. Preparing the nebulized medication in the nebulizer

a. Make sure the liquid medication is not out-of-date and has been properly stored, and that the nebulizer itself is properly functioning.

b. Place the liquid medication in the nebulizer bowl using the quantity prescribed.

• A minimum of liquid medication is needed to be able to nebulize. A volume of around 2 mL to 3 mL is a reasonable amount to use for nebulization.

• More volume than this can be used, but realize that the more the volume of liquid medication used, the longer the nebulizer time.

c. Jet nebulizers all have a residual volume after nebulization that never exits the nebulizer bowl. The higher the volume of liquid medication put into the nebulizer bowl initially, the greater the percentage of that medication will be delivered to the patient, and less active medication left as a residual in the nebulizer bowl. Using a starting volume of at least 4 mL of nebulizer solution that can be administered within 10 minutes using flow rates of 8 L/min may help minimize drug wastage. Tapping on the nebulizer chamber during nebulization may further reduce dead volume.

3. Nebulizing the medication

a. The child should be in a relaxed position, with something he or she can do or read to keep occupied during the nebulization period.

b. Ideally, with proper training, the child should be allowed to hold the nebulizer and carry out the nebulization by himself or herself. For young patients, however, the parent will need to be closely involved with the nebulization.

c. The ideal way the child should nebulize is by using a mouthpiece on the nebulizer bowl and having the mouthpiece fully in his or her mouth. Second best, but often necessary for infants and toddlers, is use of a mask that is placed securely around the child's mouth and nose. A blow-by technique can be used for infants, if absolutely necessary, but it is not recommended.

d. The child in a crying state does not allow for effective nebulization. It is preferred to have the child breathing quietly. Nebulizing a child during sleep is an option, as long as the mist is applied closely to the face, preferably with a mask.

e. The child should take slow and deep inhalations, if old enough, with occasional short rests every approximately 30 seconds.

f. Some children who are using the mouthpiece for nebulization need to wear a nose clip to occlude the nose to ensure that inhalation of the medication takes place via the mouth, and not via the nose.

g. Nebulization of a typical dose of medication usually takes anywhere from 5 minutes up to 15 minutes, depending on the nebulizer type used, the initial volume of medication, the depth and rate of breathing, and the overall cooperation of the child. The majority of nebulized dose is delivered during the first 5 minutes in most cases, and little additional benefit is gained by extending nebulization time beyond 5 to 10 minutes. When sputtering of the nebulizer bowl is noted, this signifies that nebulization is done, and no further medication is going to be able to come out of the nebulizer. A disappearance of nebulizer mist coming out of the nebulizer will be seen around this time.

Compressors for home use:

Infection control-Repeated use of disposable nebulizers may lead to bacterial contamination and nosocomial infection. Home nebulizers meant for longer-term use can also be contaminated with bacteria, but standardized guidelines for disinfecting home nebulizers are not available. At the least, home nebulizers should be rinsed and air dried between uses to prevent clogging of the Venturi mask, and to reduce microbial contamination. It is also recommended that nebulizers be disinfected by soaking once or twice per week in an acetic acid solution for 30 minutes (1 part distilled white vinegar to 3 parts warm water) or in a commercial quaternary ammonium compound for 10 minutes, although even these measures may not provide optimal sterilization. The final rinse should be with tap water. Home nebulizers and the compressor filter should be replaced every 6 months.

Allergen control-The reservoirs of home nebulizers also may be contaminated by indoor allergens (such as cockroach, cat, dog, and mouse). Proper cleaning of nebulizers, as described above, and storage of nebulizers in plastic bags may prevent contamination with allergens.

Performance deterioration-Deterioration of performance of nebulizers used at home may occur when used repetitively. This risk can be minimized by properly maintaining and rinsing the units between uses. The replacement time interval should be based upon the manufacturer's recommendation for each specific nebulizer but should not exceed 6 months.

Used with permission from Chitra Dinakar, MD, FAAP, University of Missouri-Kansas City, and Children’s Mercy Hospitals and Clinics, Kansas City; and Michael J. Welch, MD, FAAP, FAAAAI, clinical professor, University of California, San Diego, School of Medicine, and co-director, Allergy and Asthma Medical Group and Research Center, San Diego. Dr Dinakar has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article. Dr Welch reports speaker fees and contracted research for Teva Pharmaceuticals.