Home nebulisation - benfits, pros and cons, how to do

1. Home nebulisation
Dr. Aditya Jindal
Interventional Pulmonologist & Intensivist
Jindal Clinics
SCO 21, Sec 20D, Chandigarh
DM Pulmonary and Critical Care Medicine (PGI Chandigarh),
FCCP

2. The respiratory tract has evolved to keep inhaled particles
out of the lungs, and to remove or inactivate them once
deposited ...

3. The adult lung
with dimensions
and generations
of the airways
with predicted
aerosol
deposition
Roy pleasants et al. Respiratory care. 2018

4. Newman S P.Ther. Deliv. (2017)

5. Factors influencing optimal delivery of inhaled
drugs
Droplet size
Impaction
Diffusion
Sedimentation
Pattern of
inhalation
Speed
Cognition, disease
severity, and
clinical status of
patient
Roy pleasants et al. Respiratory care. 2018
Particles <5 µm  peripheral airways
Particle > 5 µm  central airways

6. Newman S P.Ther. Deliv. (2017)

7. Inhaler devices

8. • Widespread hand-held inhalers’ devices are
represented by
• Dry powder inhalers (DPIs)
• Pressurized metered dose inhalers (pMDIs)
• Soft mist inhalers (SMIs)
• Nebulizers are often left for the treatment of acute
conditions such as COPD exacerbations or in
patients with extremely limited self-sufficiency.
Inhaler devices??
Dolovich MB, Ahrens RC, Hess DR, et al. Chest. 2005;127(1):335–371.

9. Advantages and disadvantages of different types of inhaler devices in
asthma and COPD
Inhaler Formulation Metering system Pros Cons
pMDI
Drug suspended or dissolved
in propellant (With surfactant
or cosolvent)
Metering valve and
reservoir
Compact and portable.
Can be used independently.
Dose counters
Slow inhalation can be achieved
Not breath actuated
Not good for elderly
Cold Freon effect
Coordination issues
Adding spacer makes it cumbersome and
costly
MDI with spacer
Drug suspended or dissolved
in propellant (With surfactant
or cosolvent)
Metering valve and
reservoir
Easy to coordinate
Decreases oropharyngeal deposition
Eliminates Cold Freon effect
DPI
Drug blend in lactose or drug
alone/drug excipient
particles/multidose blister
reservoirs
Capsules/blisters/
Compact and portable
Do not require coordination
Doesn’t contain propellants
Requires minimum inspiratory flow
Cant be used in emergencies
Difficult in patients with cognitive
impairment and elderly
Most are moisture sensitive
SMI
Aqueous solution or
suspension
Unit dose blisters or
reservoirs
Compact and portable
Doesn’t contain propellants
Smaller dose of bronchodilator is
required
Metered volume of 15 mcl limits the
dose deliver capacity
Paola Rogliani et al. Respiratory Medicine 124 (2017) 6e14

10. Device errors in asthma and COPD:
Meta analysis
• Studies in adult males and females with asthma or COPD,
reporting at least one overall or critical error, using metered
dose inhalers and dry powder inhalers were included.
• Random-effect metaanalyses were performed to estimate
device error rates and to compare pairs of devices.
H.Chrstyn et al.npj Primary Care Respiratory Medicine (2017) 27:22

11. Meta-analysis of the overall error rate frequency for pMDI in prospective/cross-sectional studies
Summary results for the MDI devices estimated an overall
error frequency of 86.8% [95% CI 79.4–91.9] of patients with
at least one error
H.Chrstyn et al.npj Primary Care Respiratory Medicine (2017) 27:22

12. Meta-analysis of the overall error rate frequency (a) for DPIs in prospective/cross-sectional
studies
H.Chrstyn et al.npj Primary Care Respiratory Medicine (2017) 27:22

13. Device errors
in asthma and
COPD:
Metaanalysis
H.Chrstyn et al.npj Primary Care Respiratory
Medicine (2017) 27:22

14. 14 Factors Influencing Device Prescription
Cleve Clin J Med. 2018 Feb;85(2 Suppl 1):S19-S27
J Assoc Physicians India. 2017 May;65(5):60-73
Chronic Obstr Pulm Dis. 2018; 5(2): 111–123.
1. Cognition
2. Manual dexterity
3. Comorbidities
4. Preference and
outlook
5. Age
6. Poor eyesight
Patient related
1.Type of drugs
2. Combination
3. Frequency of
dosing
4. Strength of dose
5. Side effects
6. Large doses (if
required)
Drug related
1. Severity of disease
2. Respiratory status-
lung condition
Disease related
Device related
1.Ease of use
2. Device efficacy
3. Cost
4. Duration of use

15. Selecting Inhalation Device should be Based on
Quality Of Actuation-inhalation Coordination & PIFR
ERS Annual Congress London 2016
15
It is also recommended that patient preferences for devices should be
considered when prescribing an inhaler, but physicians must be cognizant
that patients often overestimate their ability to handle a device correctly

16. 16
Ann Am Thorac Soc. 2017 Aug;14(8):1305-1311
1. sPIF is common during AECOPD and predicts all-cause and COPD readmission. Patients with sPIF
may benefit therapies.
2. We recommend checking PIF in patients hospitalized for AECOPD for selection of delivery devices
1. Suboptimal PIFR (<60 L/min) has been observed in 19%-78% of stable outpatients and 32%–52% of
inpatients before discharge from the hospital after treatment for COPD exacerbation
2. Patients with COPD and sPIFR had more severe dyspnea than patients with similar
obstruction and optimal PIFR
https://doi.org/10.1164/ajrccm-conference.2019.199.1_MeetingAbstracts.A1132

17. 17
Benefit of nebulization in patients with sub-optimal PIFR
Ann Am Thorac Soc. 2017;14:1305–1311; J COPD Found. 2017;4:217–224.
• Patients with suboptimal PIFR (<60L/min) discharged with nebulizers had significantly
lower rates of COPD readmission as compared with those discharged on DPIs.
Hospital Readmission
70
50
17
10 20 30 40 50 60 70 80 90 100
% of COPD-readmission < 90 D
% of COPD-readmission < 30 D
Nebulizer DPI
(N=12) (N=10)
P<0.005
P<0.011

18. • Drug delivery via nebulization:
• An effective alternative
• An optimal dose can be delivered during tidal
breathing.
• Can be used with diferent disease severity or
associated comorbidities,
• Overcomes the need for coordination, specific
handling and inspiratory maneuvers
Nebulized devices??
Pierachille Santus, Dejan Radovanovic, Andrea Cristiano et al.2017:11 3257–3271

19. Types of
Nebulizers
Alok G.Ghosal et al. Journal of The Association of Physicians of India.2017;65:60-73

20. L. Vecellio. Breathe Mar 2006
Jet nebuliser

21. L. Vecellio. Breathe Mar 2006
Ultrasonic nebuliser

22. L. Vecellio. Breathe Mar 2006
Mesh nebuliser

23. Patient profile for Nebulization
• Patients with severe disease and exacerbations
• During exacerbations where higher doses are needed
• Elderly patients>60 years
• Patients with physical and cognitive limitations
• Patient preference
Eur Respir J 2001; 18: 228–242
Ann Transl Med 2019;7(18):487

24. What guidelines say about
nebulization?

25. GOLD 2020
GOLD guidelines 2020

26. Algorithm to identify
OAD patients for
maintenance
nebulization
*Clinical improvement should be assessed as
recommended by the respective treatment
guidelines.
#Device technique should be assessed as per the
patient information literature provided with the
device.
+Unsatisfactory device technique is any deviation
from the recommended device technique described
in the patient information literature provided with
the device
Alok G.Ghosal et al. Journal of The Association of
Physicians of India.2017;65:60-73
Indian consensus
statement on
maintenance
nebulization

27. Guidelines
in snapshot
Cassandra D. Benge and John Alan Barwise. Federal practitioner (2020),160-163

28. Drugs available
in India for
maintenance
Nebulization
Ghoshal AG, Salvi S, Dhar R, et al. J Assoc Physicians India. 2017;65(5):60-73.

29. Nebulization in COVID 19 pandemic

30. COVID 19 transmission
• Spread by droplets generated as bioaerosols.
• Aerosol transmission of SARS-CoV-2 is now considered to be
the main method of transmission because the virus can remain
viable and infectious in aerosols for hours
Ari A. Respir Med. 2020;167:105987.

31. Fugitive emissions during nebulization
Fugitive emission is defined
as aerosols that have been
released from the aerosol
device during patient
expiration.
It is also medical aerosols
that are not inhaled by the
patient but passes into the
atmosphere.
Previous studies: the
particle size ranges from
0.860 to 1.437 μm
Up to 50% of the generated
aerosol during therapy was
fugitive aerosol remain
airborne in the indoor
environment for several
hours .
Factors affecting fugitive emissions: The device,
interface, patient type, and flow rate of nebulizer,
dimensions and layout of the room, air turbulence,
airflow rates, and temperature impact dispersion and
decay
Ari A. Respir Med. 2020;167:105987.

32. Respir Care 2015

33. Advise patients to have their full supply of
medication at home1
Perform nebulization in a well ventilated room
Prevent your caretaker/family member from
staying inside the room during nebulization
DON’T let the caretaker get too close while
Nebulization is being conducted. Maintain
distance of at least 6 feet from the patient.
Close the door while nebulization is being
undertaken.2
DON’T share nebulizers between
family members. Every nebulizer
should be a single-use nebulizer2.
Avoid air-conditioning in the room
altogether5.
DO leave the room vacant with the
door closed for 30 minutes after the
patient has vacated the room post-
nebulization.4
Wash the accessories as per the guide
and use disinfectants like Isopropanol
(70%) or Hydrogen Peroxide (3%) 4.
1WHO Interim guidelines 2019; 2CDC guidelines www.health.state.mn.us; 3https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html;
4https://www.health.qld.gov.au/data/assets/pdf_file/0038/939656/qh-covid-19-Infection-control-guidelines.pdf; 5www.ncdc.gov
Good Nebulization Practice at HOME Setting

34. Advantages of Nebulization
J Assoc Physicians India. 2017 May;65(5):60-73; Nurse Prescribing. 2016 Dec 2;14(12):586-92
Med Devices (Auckl). 2015 Feb 12;8:131-9; Clinical Pediatrics;Vol. 47 No. 8; 2008
1. No patient coordination required.
2. Efficient delivery possible in patients with low
inspiratory flow rate
3. Breath holding not required
4. Large doses can be administered

35. • Issues with nebulisation
• Droplet size formed is not uniform; may vary over 10 fold
• Dose delivery depends on
• Initial volume fill
• Efficiency of aerosolisation of medicine
• Amount residual/dead volume (0.5 – 1.5 ml)
• Breath actuation vs continuous use

36. Newman S P.Ther. Deliv. (2017)

37. Alhaddad B et al. BMJ Open Resp Res 2015

38. Alhaddad B et al. BMJ Open Resp Res 2015

39. Cochrane Review: Nebulizers vs pMDI vs DPI
• There is a lack of evidence in favour of one mode of delivery over
another for bronchodilators during exacerbations of COPD.
• No difference between nebulisers versus pMDI plus spacer regarding
the primary outcomes of FEV1 at one hour and safety.
• Secondary outcome: Change in FEV1 closest to one hour after dosing'
during an exacerbation of COPD, a greater improvement in FEV1
when treating with nebulisers than with pMDI plus spacers.
Bronchodilators delivered by nebuliser versus pMDI with spacer or DPI for exacerbations of COPD. Cochrane Database of Systematic Reviews 2016, Issue 8. Art.
No.: CD011826.

40. Summary
• Inhalation therapy is the preferred route of drug administration for treating COPD.
• In comparison with pMDIs and DPIs, effective drug delivery with conventional pneumatic nebulizers
requires less intensive patient training.
• However, home nebulisation has its own problems and issues
• If nebulized medications need to be used in patients with COVID-19 adequate precautions should be taken