Nebulisation is a method of converting a medicine or solution into an aerosol, which is inhaled directly into the lungs.
The aim of nebulisation treatment is to deliver a therapeutic dose of medicine (in the form of breathable particles) over a period of time, usually five to 10 minutes (Boe et al 2001) Nebulisers are indicated for use in a variety of situations including:
- when a child or young person has an acute asthma attack
- when a child or young person is in respiratory distress
- when a child or young person has stridor
- before physiotherapy to loosen secretions
- if child or young person is unable to use an inhaler
- the medicine required is not available in an inhaler preparation (Bennett 2003, Kelly and Lynes 2011)
- when large doses of nebulised antibiotics are required to treat or control persistent infections (Daniels at al 2013).
The most common solutions and medicines to be nebulised are bronchodilators, sodium chloride (0.9% and hypotonic), bronchodilators, adrenaline, steroids and antibiotics (Bennett 2003). Water should never be nebulised (Rationale 1).
Nebulisers are attached to either compressed air units (can be used in children of all age groups) (Rationale 2) (Watt 2003) or to the oxygen or air ports, depending on the child / young person’s underlying condition. In the intensive and transitional care units electronic nebuliser sets are used to deliver drugs through the ventilator circuit by placing the set on the dry side of the ventilator tubing before the humidifier (Ari et al 2010).
Preparing the child and family
Inform the child or young person and their family of the need to administer a nebuliser. Identify any previous experience the child or young person has of receiving nebuliser therapy and how this was tolerated (Rationale 3).
Using age and/or developmentally appropriate language, explain the procedure to the child or young person (Rationale 4).
Explain this to the parent/carer as well (Rationale 5, Rationale 6).
If possible, allow the child or young person some control and choice about the procedure such as using a mask or a mouthpiece, or who should hold the nebuliser (Rationale 7, Rationale 8) (Booker, 2007, Porter-Jones 2000a).
A set of observations should be recorded before commencement of the nebuliser, if this is to be administered for respiratory distress, stridor or asthma. The CEWS score should be recorded.
Preparing the nebuliser medication
All medications should be drawn up and administered according to the medicines administration policy (Rationale 9).
Some dosages of the prescribed medication may give a small solution volume. In order to be effective, nebulisers should only be administered with volumes equal to or greater than 2.5ml and different medicines should be administered separately (Rationale 10, Rationale 11,Rationale 12) ( Boe et al,2001). Any volume deficit should be corrected using 0.9% sodium chloride (never water) and checked as policy (Rationale 13). Note: if using an electronic delivery system, the volumes required are smaller. Please refer to manufacturer guidelines (Barnett, 2007).
Syringes containing nebuliser solutions should not be taken to the patient at the same time as medications to be delivered by an alternative route (such as oral or intravenous) (Rationale 14).
Assembling the nebuliser set
The most common nebuliser used in the hospital is the basic jet nebuliser, although newer delivery systems are available involving an electronic delivery system (Dolovich and Dhand, 2011). When using any nebuliser, reference should be made to manufactures’ guidance (Rubin 2011).
This guideline details the process for administration via the jet nebuliser system.
The nebuliser sets come with three components:
- the chamber (also called the 'pot' or 'acorn') (Rationale 15)
- a mouthpiece or mask (Rationale 16)
- and tubing (Rationale 17)
The chamber comes in three parts:
- The base of the chamber has a gas inlet. This is the part of the chamber that the solution should be put into and to the bottom of which the tubing is attached (Rationale 18).
- Over the gas inlet, there is a detachable mushroom shaped piece of plastic (the dispersal component). Without it the nebuliser would not work properly (Rationale 19).
- The top of the chamber (usually blue) is designed to screw back onto the base. It is also designed to accept either a mask or a mouthpiece for administration of the nebuliser (Rationale 20).
Administering the nebuliser
Communicate with the child or young person that the nebuliser is being prepared. Make sure that the mask is an appropriate size for the child or young person. For patients with tracheostomies, a 'trache mask' (Rationale 21) must be used for administering a nebuliser (Rationale 22, Rationale 23).
Using a clean technique and with the appropriate administration checks in line with the Medicines Administration Policy, instil the solution to be nebulised into the dry chamber, ensuring it has a volume equal to, or greater than, 2.5ml (Rationale 23). Ensure the dispersal piece is in place (Rationale 24). Attach the top of the chamber (usually screw on) (Rationale 25). Attach the tubing to the gas inlet (Rationale 26) and set flow.
If age appropriate, encourage the child to sit up straight to receive their nebuliser and to take normal steady breaths during administration (Rationale 27). The child / young person should be asked not to talk while the nebuliser is running and to ensure the nebuliser is kept upright (Rationale 28). Babies may be placed in a head-up tilt position or in a chair (Rationale 29).
Toddlers and pre-schoolers may need some form of distraction to keep them occupied during administration (Rationale 30).
Attach the tubing to either the air or oxygen flow meter available at the bedside (Rationale 31).
If oxygen is used it must be prescribed.
Ensure the choice of gas (air or oxygen) is suitable for the patient. Nebulisers should only be given using oxygen if:
- The patient is oxygen dependant.
- The patient is in acute respiratory distress and requires additional oxygen therapy (Boe et al 2001).
At all other times, air should be used for administering nebulisers (Boe et al 2001). In September 2009, the National Patient Safety Agency (NPSA) issued a Rapid Response Report (RRR) to all hospital settings with actions to improve oxygen safety, particularly the risk of using an air port rather than an oxygen port in an emergency situation. When air is being used for the nebuliser, oxygen should be available at all times.
Assist the child to position the face mask or mouthpiece (Rationale 32) before the flow is turned on. The flow meter should be set to deliver at 6-8l/minute (Rationale 33, Rationale 34) (Boe et al 2001, Porter-Jones 2000b;).
Note: if using an electronic delivery system this will not apply as the nebuliser has an electronic unit to create the aerosol.
Nebulisers take on average five to ten minutes to administer (Bennett 2003, Watt 2003). European Respiratory Society Guidelines on the use of nebulisers (Boe et al 2001) allow for up to 15 minutes for administration as a maximum (Rationale 35).
When the aerosol becomes less apparent, but there is obviously still solution that could be nebulised, the child/nurse/carer should gently tap the chamber (Rationale 36). When no further aerosol can be seen and the nebuliser set sounds 'empty', the nebuliser is complete and the gas should be turned off. Assist the child to remove the mask/mouthpiece.
Document that the nebuliser has been given and any effect it has had on the child / young person (Rationale 37, Rationale 38). Young children may initially appear worse symptomatically following a nebuliser and should be allowed to settle before effectiveness is assessed (Rationale 39). A set of observations should be recorded after the completion of the nebuliser, if this was administered for respiratory distress, stridor or asthma. The CEWS score should be recorded.
Administering antibiotics by nebuliser
Large doses of nebulised antibiotics are sometimes used to treat or control persistent infections in the airways without increasing antibiotic systemic levels. This avoids the side effects of antibiotics given by alternative routes.
Before antibiotic nebuliser treatment is started children over five years should have lung function recorded pre and post the first dose. Children under five years or those unable to carry out lung function should have their saturations monitored and recorded throughout the procedure and for 10 minutes afterwards.
Before administration of the first dose, all children / young people also need chest auscultation prior to the procedure and at the end to check for any bronchoconstriction. A bronchodilator should be prescribed and available in case of an adverse reaction.
Any nebulised antibiotics should be administered using a nebuliser set with a filter and should be given using a mouthpiece (Rationale 40) when possible. The filter pad must be changed daily (Rationale 41). Staff should wear masks and personal protective equipment when administering an antibiotic nebuliser.
Post-procedure cleaning of equipment
Disconnect the nebuliser set from the tubing and the flow meter. Take the nebuliser chamber apart, so that the three components are separated from each other (Rationale 42).
Ensure any residual solution is discarded (Rationale 43, Rationale 44, Rationale 45).
Wash the three parts of the chamber in warm soapy (neutral detergent/washing up liquid) water. Chlorhexidine-based or other soap products are not suitable (Rationale 46).
Rinse all three parts well (Rationale 47).
Remove excess water with paper towel (Rationale 48).
Leave the nebuliser parts in a clean area to air dry (manufacturer’s guidelines for cleaning in a hospital setting) (Rationale 49). This should be away from any area where water may splash on it to reduce the risk of contamination.
Staff should regularly review the integrity of the nebuliser set (Rationale 50).
Discard the chamber and tubing if either shows any signs of the following (Rationale 51):
- cracking of the chamber (Edwards 2001)
Each single patient use nebuliser set should be used for a maximum of one week before being routinely discarded (Rationale 52) (Edwards 2001). The set should be labelled (on the tubing rather than pot) and any changes of set documented in the nursing notes.
Rationale 1: It may cause bronchoconstriction (Boe et al 2011).
Rationale 2: Depending on age, a facemask or mouthpiece can be used, making nebuliser therapy accessible to all ages.
Rationale 3: To facilitate an appropriate explanation of nebuliser administration.
Rationale 4: To allow the child / young person the opportunity to ask questions and discuss concerns.
Rationale 5: To facilitate an open working partnership with the parent/carer and provide the opportunity to ask questions and discuss concerns.
Rationale 6: To reduce anxiety and facilitate successful delivery or the nebulised drug/solution.
Rationale 7: Nebulisers are rarely given unless there is clinical need. Explain to the child that the nebuliser needs to be given, and will be given, but they have some choices about how that is done.
Rationale 8: To ensure the safety of the child at all times.
Rationale 9: To minimise the risk of an incorrect dose being administered and to adhere to Policy
Rationale 10: This is due to the concentrations provided of certain medication.
Rationale 11: There is always a residual amount of solution left at the end of nebulisation. In order to minimise the amount of drug “wasted” in this residue, the starting volume needs to be at least 2.5ml (Boe et al, 2001).
Rationale 12: Not all drugs that can be nebulised should be mixed together (e.g. steroids and bronchodilators cannot be mixed).
Rationale 13: Water should never be nebulised (Boe et al, 2001) therefore 0.9% sodium chloride is the most suitable solution to use to “make up” the required volume.
Rationale 14: To avoid potential errors in route of administration.
Rationale 15: The chamber will house the solution to be nebulised.
Rationale 16: Mouthpieces should be used whenever antibiotics or steroids are nebulised to prevent their exhalation into the air and to minimise deposits of the drug on the child’s face.
Rationale 17: The tubing is used to attach the gas inlet on the chamber to either an air or oxygen supply.
Rationale 18: The circulation of air or oxygen around the chamber, coupled with the movement of the dispersal piece, causes the atomisation of the solution.
Rationale 19: The large particles which result from this process then impact on the baffles (the sides of the dispersal piece) to produce smaller inspirable particles.
Rationale 20: Using a mask or mouthpiece will concentrate the flow of the aerosol from the nebuliser. Which piece is used will depend on the patient’s needs or personal preferences.
Rationale 21: The “trache mask” fits over the tracheostomy providing optimal inhalation therapy from the nebuliser.
Rationale 22: Appling a face mask or asking a child with a tracheostomy to use a mouthpiece will result in little or no benefit from the nebuliser as the tracheostomy is their airway, not their nose and mouth.
Rationale 23: To ensure optimal nebulisation and minimal “wastage” of the drug.
Rationale 24: To ensure nebulisation occurs.
Rationale 25: To allow attachment of an appropriate mask or mouthpiece.
Rationale 26: For administration of air/oxygen to facilitate nebulisation.
Rationale 27: Sitting upright allows for maximum lung expansion (Boe et al,2001).
Rationale 28: This will ensure optimal therapy is gained.
Rationale 29: To have them in as close to a sitting position as possible.
Rationale 30: To minimise any distress caused by having to stay in one place for five to 10 minutes.
Rationale 31: To enable the nebuliser to function.
Rationale 32: To ensure correct position and to maximise the benefit of the nebuliser.
Rationale 33: Aerosol must be visible to ensure the nebuliser efficacy.
Rationale 34: Do not set the flow meter too high, this could be uncomfortable for the patient to breathe against.
Rationale 35: Length of administration will vary according to the amount of solution used.
Rationale 36: This will agitate the solution in the chamber, ensuring the maximum possible is nebulised.
Rationale 37: To ensure an accurate record of administered medications and to adhere to the Trust Medicines Administration Policy.
Rationale 38: To ensure an accurate record of the effectiveness of the nebuliser is maintained.
Rationale 39: This can be due to the distress of being restricted in movement for the duration of the nebuliser or having to wear a face mask.
Rationale 40: To prevent exhalation of the antibiotic into the air (Bennett 2003).
Rationale 41: To ensure the filter is fully effective.
Rationale 42: To facilitate thorough cleaning of the chamber.
Rationale 43: Any residual solution left in the chamber will rapidly become colonised with bacteria from environmental sources (Edwards 2001).
Rationale 44: Pseudomonas aeruginosa is commonly found to contaminate nebulisers (Edwards 2001). Many patients requiring nebuliser therapy have pre-existing respiratory tract infections, which may be bacterial, fungal or viral in origin (Bennett 2001).
Rationale 45: If not discarded promptly, this will contaminate the water used to wash out the chamber.
Rationale 46: Washing the chamber ensures no residual drug is left in the nebuliser set avoiding subsequent re-administration with the next nebuliser.
Rationale 47: To ensure no drug or soap residue left in set
Rationale 48: Any residual water left in the chamber may rapidly become colonised with bacteria from environmental sources (Bennett 2001), so must be allowed to dry thoroughly.
Rationale 49: Nebuliser sets are single patient use, not single use, and can therefore be used repeatedly for the same patient for up to one week in hospital.
Rationale 50: To ensure there is no risk to the patient of inhaling a microorganism that could have infected the chamber and/or tubing.
Rationale 51: To ensure the nebuliser set is administering optimal therapy to the child.
Rationale 52: This is manufacturer’s guidance to ensure the continued effectiveness of the nebulisers and to minimise to risk of cross infection.
Ari, A., Atalay, O.T., Harwood, R., Sheard, M.M., Aljamhan, E.A. and Fink, J.B. (2010) Influence of nebulizer type, position, and bias flow on aerosol drug delivery in simulated pediatric and adult lung models during mechanical ventilation. Respiratory care, 55(7): 845-851.
Barnett, M. (2007) Drug delivery: nebuliser therapy. Journal of Community Nursing, 21(6):10.
Bennett, C. (2003) Nursing the breathless patient. Nursing Standard, 17(17): 45.
Boe, J., Dennis, J.H., O'Driscoll, B.R., Bauer, T.T., Carone, M., Dautzenberg, B., Diot, P., Heslop, K. and Lannefors, L. (2001) European Respiratory Society Guidelines on the use of nebulizers Guidelines prepared by a European Respiratory Society Task Force on the use of nebulizers. European Respiratory Journal, 18(1): 228-242.
Booker, R. (2007) Correct use of nebulisers. Nursing standard, 22(8):39.
Daniels, T., Mills, N. and Whitaker, P. (2013) Nebuliser systems for drug delivery in cystic fibrosis. The Cochrane Library.
Dolovich, M.B. and Dhand, R. (2011) Aerosol drug delivery: developments in device design and clinical use. The Lancet, 377(9770):1032-1045.
Edwards, A. (2001) Decontamination of nebulisers. Nursing Times, 97(7): III.
Kelly, C. and Lynes, D. (2011) Best practice in the provision of nebuliser therapy. Nursing Standard, 25(31): 50.
National Patient Safety Agency. (2009) Oxygen Safety in hospitals. Rapid Response Report. NPSA/2009/RRR006. [Accessed on 26/01/2016].
Porter-Jones, G. (2000a) Nebulisers--1: Preparation. Nursing times, 96(36): 45.
Porter-Jones, G. (2000b) Nebulisers--2: Administration. Nursing times, 96(37): 51.
Rubin, B.K. (2011) Pediatric aerosol therapy: new devices and new drugs. Respiratory care, 56(9): 1411-1423.
Watt, S. (2003) Safe administration of medicines to children: part 2: The roles and responsibilities of the nurse in administering medicines are discussed by Sigrid Watt in the second part of her two part article. Paediatric Care, 15(5): 40-44.