Use of medication nebulizers in children
- Robert H Moore, MD
Robert H Moore, MD
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Section Editors
- Gregory Redding, MD
Gregory Redding, MD
- Section Editor — Pediatric Pulmonology
- Professor of Pediatrics
- University of Washington School of Medicine
- Robert A Wood, MD
Robert A Wood, MD
- Editor-in-Chief — Allergy and Immunology
- Section Editor — Pediatric Allergy
- Professor of Pediatrics
- Johns Hopkins University School of Medicine
The delivery of aerosolized medication is an important component of treatment for many respiratory disorders in children. Glucocorticoids, bronchodilators, antibiotics, mucus hydration agents, and mucolytic agents can be administered via aerosol.
Nebulizer devices are widely used to deliver aerosol therapy, especially in children. A wide variety of nebulizers are available for use in the home and hospital, with varying capacities to deliver drugs to the lungs . Clinicians must consider how a particular nebulizer performs with the specific drug to be administered to ensure its clinical suitability [1-4].
The use of medication in nebulizers for children is presented here. An overview of aerosolized medication delivery in children and the use of pressurized metered dose inhalers are discussed separately. (See "Delivery of inhaled medication in children" and "The use of inhaler devices in children".)
Nebulizers are used to provide aerosol therapy to patients too ill or too young to use handheld devices and in situations where large drug doses are necessary. These devices also are required for some medications available only in liquid form, including pentamidine, ribavirin, DNAase, hypertonic saline, and tobramycin.
The potential benefits of nebulizers need to be balanced with the disadvantages associated with the use of these devices. These include higher costs, longer set-up and delivery time, decreased portability, variable nebulizer performance, and (with jet nebulizers) the need for a source of compressed air or oxygen.
- Coates AL, Ho SL. Drug administration by jet nebulization. Pediatr Pulmonol 1998; 26:412.
- O'Donohue WJ Jr. Guidelines for the use of nebulizers in the home and at domiciliary sites. Report of a consensus conference. National Association for Medical Direction of Respiratory Care (NAMDRC) Consensus Group. Chest 1996; 109:814.
- Dolovich MA, MacIntyre NR, Anderson PJ, et al. Consensus statement: aerosols and delivery devices. American Association for Respiratory Care. Respir Care 2000; 45:589.
- Hardy JG, Newman SP, Knoch M. Lung deposition from four nebulizers. Respir Med 1993; 87:461.
- Hess D, Fisher D, Williams P, et al. Medication nebulizer performance. Effects of diluent volume, nebulizer flow, and nebulizer brand. Chest 1996; 110:498.
- Daniels T, Mills N, Whitaker P. Nebuliser systems for drug delivery in cystic fibrosis. Cochrane Database Syst Rev 2013; 4:CD007639.
- Hess DR. Nebulizers: principles and performance. Respir Care 2000; 45:609.
- Clay MM, Pavia D, Newman SP, Clarke SW. Factors influencing the size distribution of aerosols from jet nebulisers. Thorax 1983; 38:755.
- Kendrick AH, Smith EC. Optimizing nebulization practice. Respir Med 1996; 90:315.
- O'Callaghan C, Barry PW. The science of nebulised drug delivery. Thorax 1997; 52 Suppl 2:S31.
- Bucholski A, Keller M, Balcke A, et al. In vitro performance of eFlowTM, an electronic inhaler for administration of a novel aztreonam formulation to CF patients. Pediatr Pulmonol Suppl 2003; 25:321.
- Lass JS, Sant A, Knoch M. New advances in aerosolised drug delivery: vibrating membrane nebuliser technology. Expert Opin Drug Deliv 2006; 3:693.
- Rubin BK, Fink JB. Aerosol therapy for children. Respir Care Clin N Am 2001; 7:175.
- O'Callaghan C, Barry PW. Asthma drug delivery devices for children. BMJ 2000; 320:664.
- O'Callaghan C, Clark AR, Milner AD. Why nebulise for more than five minutes? Arch Dis Child 1989; 64:1270.
- Malone RA, Hollie MC, Glynn-Barnhart A, Nelson HS. Optimal duration of nebulized albuterol therapy. Chest 1993; 104:1114.
- Dennis JH, Hendrick DJ. Design characteristics for drug nebulizers. J Med Eng Technol 1992; 16:63.
- Wildhaber JH, Dore ND, Wilson JM, et al. Inhalation therapy in asthma: nebulizer or pressurized metered-dose inhaler with holding chamber? In vivo comparison of lung deposition in children. J Pediatr 1999; 135:28.
- Clay MM, Pavia D, Newman SP, et al. Assessment of jet nebulisers for lung aerosol therapy. Lancet 1983; 2:592.
- Coates AL, MacNeish CF, Meisner D, et al. The choice of jet nebulizer, nebulizing flow, and addition of albuterol affects the output of tobramycin aerosols. Chest 1997; 111:1206.
- Reisner C, Katial RK, Bartelson BB, et al. Characterization of aerosol output from various nebulizer/compressor combinations. Ann Allergy Asthma Immunol 2001; 86:566.
- Coates AL, MacNeish CF, Lands LC, et al. A comparison of the availability of tobramycin for inhalation from vented vs unvented nebulizers. Chest 1998; 113:951.
- Hess DR, Acosta FL, Ritz RH, et al. The effect of heliox on nebulizer function using a beta-agonist bronchodilator. Chest 1999; 115:184.
- Kress JP, Noth I, Gehlbach BK, et al. The utility of albuterol nebulized with heliox during acute asthma exacerbations. Am J Respir Crit Care Med 2002; 165:1317.
- Henderson SO, Acharya P, Kilaghbian T, et al. Use of heliox-driven nebulizer therapy in the treatment of acute asthma. Ann Emerg Med 1999; 33:141.
- Anderson M, Svartengren M, Philioson K, et al. Deposition in man of particles suspended in air or in helium-oxygen mixture at different flow rates. J Aerosol Med 1990; 3:209.
- Anderson M, Svartengren M, Bylin G, et al. Deposition in asthmatics of particles inhaled in air or in helium-oxygen. Am Rev Respir Dis 1993; 147:524.
- Habib DM, Garner SS, Brandeburg S. Effect of helium-oxygen on delivery of albuterol in a pediatric, volume-cycled, ventilated lung model. Pharmacotherapy 1999; 19:143.
- Svartengren M, Anderson M, Philipson K, Camner P. Human lung deposition of particles suspended in air or in helium/oxygen mixture. Exp Lung Res 1989; 15:575.
- Bigham MT, Jacobs BR, Monaco MA, et al. Helium/oxygen-driven albuterol nebulization in the management of children with status asthmaticus: a randomized, placebo-controlled trial. Pediatr Crit Care Med 2010; 11:356.
- Ho SL, Coates AL. Effect of dead volume on the efficiency and the cost to deliver medications in cystic fibrosis with four disposable nebulizers. Can Respir J 1999; 6:253.
- Schueepp KG, Devadason SG, Roller C, et al. Aerosol delivery of nebulised budesonide in young children with asthma. Respir Med 2009; 103:1738.
- Kundoor V, Dalby RN. Assessment of facial and ocular deposition of nebulized aerosol using a color-based method. Drug Dev Ind Pharm 2010; 36:1281.
- Fink JB. Aerosol device selection: evidence to practice. Respir Care 2000; 45:874.
- Barry PW, O'Callaghan C. An in vitro analysis of the output of budesonide from different nebulizers. J Allergy Clin Immunol 1999; 104:1168.
- Barry PW, O'Callaghan C. An in vitro analysis of the output of salbutamol from different nebulizers. Eur Respir J 1999; 13:1164.
- Devadason SG, Everard ML, Linto JM, Le Souëf PN. Comparison of drug delivery from conventional versus "Venturi" nebulizers. Eur Respir J 1997; 10:2479.
- Wildhaber JH, Devadason SG, Eber E, et al. Effect of electrostatic charge, flow, delay and multiple actuations on the in vitro delivery of salbutamol from different small volume spacers for infants. Thorax 1996; 51:985.
- Nikander K, Agertoft L, Pedersen S. Breath-synchronized nebulization diminishes the impact of patient-device interfaces (face mask or mouthpiece) on the inhaled mass of nebulized budesonide. J Asthma 2000; 37:451.
- Sabato K, Ward P, Hawk W, et al. Randomized controlled trial of a breath-actuated nebulizer in pediatric asthma patients in the emergency department. Respir Care 2011; 56:761.
- Papo MC, Frank J, Thompson AE. A prospective, randomized study of continuous versus intermittent nebulized albuterol for severe status asthmaticus in children. Crit Care Med 1993; 21:1479.
- Katz RW, Kelly HW, Crowley MR, et al. Safety of continuous nebulized albuterol for bronchospasm in infants and children. Pediatrics 1993; 92:666.
- Moler FW, Johnson CE, Van Laanen C, et al. Continuous versus intermittent nebulized terbutaline: plasma levels and effects. Am J Respir Crit Care Med 1995; 151:602.
- Moler FW, Hurwitz ME, Custer JR. Improvement in clinical asthma score and PaCO2 in children with severe asthma treated with continuously nebulized terbutaline. J Allergy Clin Immunol 1988; 81:1101.
- Portnoy J, Nadel G, Amado M, Willsie-Ediger S. Continuous nebulization for status asthmaticus. Ann Allergy 1992; 69:71.
- Portnoy J, Aggarwal J. Continuous terbutaline nebulization for the treatment of severe exacerbations of asthma in children. Ann Allergy 1988; 60:368.
- McPeck M, Tandon R, Hughes K, Smaldone GC. Aerosol delivery during continuous nebulization. Chest 1997; 111:1200.
- Voss KR, Willsie-Ediger SK, Pyszczynski DR, Nelson KA. Description of a delivery method for continuously aerosolized albuterol in status asthmaticus. J Asthma 1990; 27:37.
- Berg EB, Picard RJ. In vitro delivery of budesonide from 30 jet nebulizer/compressor combinations using infant and child breathing patterns. Respir Care 2009; 54:1671.
- Loffert DT, Ikle D, Nelson HS. A comparison of commercial jet nebulizers. Chest 1994; 106:1788.
- Standaert TA, Vandevanter D, Ramsey BW, et al. The choice of compressor effects the aerosol parameters and the delivery of tobramycin from a single model nebulizer. J Aerosol Med 2000; 13:147.
- Jakobsson BM, Onnered AB, Hjelte L, Nyström B. Low bacterial contamination of nebulizers in home treatment of cystic fibrosis patients. J Hosp Infect 1997; 36:201.
- Hutchinson GR, Parker S, Pryor JA, et al. Home-use nebulizers: a potential primary source of Burkholderia cepacia and other colistin-resistant, gram-negative bacteria in patients with cystic fibrosis. J Clin Microbiol 1996; 34:584.
- Wexler MR, Rhame FS, Blumenthal MN, et al. Transmission of gram-negative bacilli to asthmatic children via home nebulizers. Ann Allergy 1991; 66:267.
- Guideline for prevention of nosocomial pneumonia. Centers for Disease Control and Prevention. Respir Care 1994; 39:1191.
- Rosenfeld M, Emerson J, Astley S, et al. Home nebulizer use among patients with cystic fibrosis. J Pediatr 1998; 132:125.
- Chatburn RL, Kallstrom TJ, Bajaksouzian SA. A comparison of acetic acid with a quaternary ammonium compound for disinfection of hand-held nebulizers. Respir Care 1988; 33:179.
- Bollinger ME, Butz A, Mudd K, Hamilton RG. Contamination of nebulizers with environmental allergens. Ann Allergy Asthma Immunol 2005; 95:429.
- Alvine GF, Rodgers P, Fitzsimmons KM, Ahrens RC. Disposable jet nebulizers. How reliable are they? Chest 1992; 101:316.
- Coates AL, Canny G, Zinman R, et al. The effects of chronic airflow limitation, increased dead space, and the pattern of ventilation on gas exchange during maximal exercise in advanced cystic fibrosis. Am Rev Respir Dis 1988; 138:1524.
- Standaert TA, Morlin GL, Williams-Warren J, et al. Effects of repetitive use and cleaning techniques of disposable jet nebulizers on aerosol generation. Chest 1998; 114:577.
- BASIC TYPES OF NEBULIZERS
- Jet nebulizers
- Ultrasonic nebulizers
- Vibrating mesh nebulizers
- FACTORS AFFECTING JET NEBULIZER PERFORMANCE
- ENHANCED JET NEBULIZER DESIGNS
- Breath-enhanced open-vent nebulizer
- Storage bag nebulizers
- Intermittent nebulizers
- Breath-actuated nebulizers
- NEBULIZERS FOR SPECIFIC MEDICATIONS
- CONTINUOUS NEBULIZATION
- USING A JET NEBULIZER
- Compressors for home use
- Infection control
- Allergen control
- Performance deterioration
- INFORMATION FOR PATIENTS