Demystifying Nebulization: Its Principle, Classification, Applications, etc. For more information, please contact us: 9779030507.

1. DEMYSTIFYING NEBULIZATION
Jindal Clinics, Chandigarh
www.jindalchest.com

2. Part A. Basic Physics and General Principles

3. Pulmonary Delivery of Drugs
• Inhalational therapy
involves Pulmonary
delivery of drugs
through airway route
• Pharmacokinetics of
inhalational drugs
almost parallel those
of intravenously
administered drugs

4. Route of delivery for airway diseases
Intravenous route
- no benefits
- Potential for increased adverse effects
Inhaled route: preferred mode
Easy, safe, faster onset of action
More effective than parenteral routes
Favors IV Favors inhaled
Travers et al Cochrane Database Syst Rev 2001

5. Factors Affecting Pulmonary Drug Delivery
• Physics of inhalation: Particle size, Flow, Inspiratory
effort, Particle deposition
• Device - Related Factors
• Nature of the device (ease of use)
• Patient - Related Factors
• Technique of use of the device
• Pattern of breathing
• Geometry of the airways
• Severity of disease

6. Airway Geometry & Particle deposition
• High variability of regional and
total deposition efficiency.
• Factors for deposition:
i. Respiratory tract geometry
ii. Breathing pattern,
iii. Age and health,
iv. Momentary physical activity
iii. Aerosol properties:
Particle size, shape,
Density,
Hygroscopicity,
Surface properties
As aerosols move into smaller and
smaller airway at bifurcations, some
particles get deposited as they reach a
point where the distance from their
center to a surface is less than their
radius.
Mechanisms of deposition

7. Particle Size & Lung deposition
• Most particles of 0.1–1 μm diffuse
by Brownian motion & deposit when
they collide with the airway wall.
• The longer the residence time in the
smaller airways, the greater the
deposition from sedimentation and
Brownian motion processes.
• Inhaled particles that do not deposit
are exhaled.
• Particles >5 μm are deposited by
impaction in the oropharynx and
swallowed.
• Particles <5 μm (fine-particle
fraction, FPF) have the greatest
potential for lung deposition, usually
deposited by sedimentation or
gravity.

8. Metered dose
inhalers
Dry powder
inhalers
Nebulizer
Inhaler Devices Classification
Breath Actuated Inhalers
BAIs

9. Pulmonary delivery of drugs: Advantages
Treatment of respiratory diseases
Inhalation
• Deliver high concentrations
directly to the disease site
• Rapid clinical response
• Minimizes risk of systemic side-
effects
• Bypass the barriers to
therapeutic efficacy, such as:
Poor gastrointestinal absorption and
First-pass metabolism in the liver
• Achieve a similar or superior
therapeutic effect at a fraction of
the systemic dose
Nebulization
• Drug delivery with an air-pump
driven by power used to convert
liquid drug into aerosols, to
deliver medication by inhalation
through a mask
• First invented in France by Sales-
Girons in 1858 to atomize the liquid
medication. The pump handle was
operated like a bicycle pump; steam-
driven nebulizer invented in
Germany in 1864 - "Siegle's steam
spray inhaler", used Venturi pump to
atomize liquid medication.

10. Nebulization - Principle
• Bernoulli Principle: when a
pressurized flow of air is directed
through a constricted orifice, the
velocity (not the pressure) of the
airflow is increased to create a jet
stream.
• The jet stream creates a sub-
atmospheric pressure zone
(vacuum) which draws the fluid
up the capillary tube.
• Nozzles also convert liquids into
a fine mist, but do so by pressure
through small holes.
• Nebulizers generally use gas
flows to deliver the mist.

11. Nebulization vs. Steam inhalation
Steam inhalation
• Warm vapours are soothing;
provides moisture to the dry mucus
membranes in the nose and throat
• Helps loosen the mucus and
provides relief from chest congestion.
• Hot vapour can help reduce
bacterial infections in the nasal
passage and reduce common cold
symptoms
• Excess hot vapour or steam
inhalation for a long time can cause
damage to the nose and throat
cells. Skin issues and swelling and
redness in the eyes.
• Greater risks in children
Nebulization
• A nebulizer breaks particles up
further to make for a finer and
deeper reach.
• Particles of more than 10 μm in
diameter are most likely to deposit
in the mouth and throat, for those
of 5–10 μm diameter a transition
from mouth to airway deposition
occurs, and particles smaller than
5 μm in diameter deposit more
frequently in the lower airways
and are appropriate for
pharmaceutical aerosols.
• Nebulizing processes have been
modeled on computational fluid
dynamics

12. Nebulizer vs. MDI
MDI
Advantages: Smaller in size
• Require no power source.
• Deliver the medicine more quickly
than a nebulizer.
• With spacer, as effective as a
nebulizer
Disadvantages: Require coordination
Difficult to administer in the elderly,
small children, patients with
disabilities and serious cases,
severe asthma attacks.
The age of the child makes a difference
in how an inhaler is used; may
require another person to
administer
Nebulizer
Advantages: For all age groups,
normal ventilatory pattern and low
inspiratory flow.
Easy for patients who have difficulty
using inhalers, such as the elderly,
small children, patients with
disabilities and serious cases,
severe asthma attacks.
Low operational cost.
Disadvantages: Creates more noise
(often 60 dB during use)
• Less portable, greater weight
• Greater dose; lot of wastage
• Local deposition in the mouth

13. Types of Nebulizers
I. Pneumatic
• Jet nebulizer or "atomizers” - connected by tubing to a supply of compressed
gas, to flow at high velocity through a liquid medicine
II. Mechanical
• Soft mist inhaler: Due to the very low velocity of the mist, the Soft Mist
Inhaler in fact has a higher efficiency compared to a conventional pMDI.
• Could be classified as a "hand driven nebulizer" and a "hand driven pMDI”
III. Electrical: Ultrasonic wave nebulizer
The electronic oscillator generates a high frequency ultrasonic wave which
causes the mechanical vibration of a piezo-electric element. This vibrating
element is in contact with a liquid reservoir and its high frequency vibration is
sufficient to produce a vapor mist.
• Vibrating mesh technology: With this technology a mesh/membrane with
1000–7000 laser drilled holes vibrates at the top of the liquid reservoir, and
thereby pressures out a mist of very fine droplets through the holes; more
efficient than having a vibrating piezoelectric element at the bottom of the
liquid reservoir, and thereby shorter treatment times are also achieved.

14. Nebulization: Indications
I. First line treatment
1. Severe asthma attack characterized by unrelieved
airway inflammation.
2. Acute exacerbation of Chronic Obstructive Pulmonary
Disease (COPD)
3. Acute worsening of disorders that cause persistent,
often progressive, airflow obstruction
i. Airway diseases (bronchitis, bronchiolitis)
ii. Alveolar conditions (emphysema)
II. Supportive treatment for persistent respiratory
symptoms
– Wheeze, Shortness of breath,
– Chest tightness and Cough

15. III. Miscellaneous disorders
• Aerosolized antibiotics for pneumonias, purulent
tracheobronchitis and alveolar infection.
• Chronic lung infection with Pseudomonas
aeruginosa in patients with cystic fibrosis or non-CF
bronchiectasis
• Liquefaction of thick, viscid bronchial secretions.
• Inhaled pentamidine (given as a 1-µm MMAD
aerosol) for Pneumocystis jirovecii pneumonia, in
patients infected with HIV
• Management of Hyperkalaemia

16. Hand-held Nebulizers/ Soft mist inhalers
• Liquid-based inhalers which
produce a slow-moving
aerosol cloud; release
medication
i. in a fine mist
ii. more slowly and
iii. lasts longer
• For delivering treatments for
short-term care
• SMI is more efficient, even with
poor inhaler technique;
teaching patients to hold their
breath as well as to inhale
slowly and deeply increases
further lung deposition
• Suitable for biologic
formulations
• Gentle aerosolization for
sensitive drug products
• Greater sustainability
• Can be reused
SMIs offer a great potential for
drug delivery of a far wider
range of drug formulations with
enhanced precision and
accuracy of dosing and
inhalation for a wider range of
drugs.

17. INHALATIONAL/ NEBULIZABLE DRU
• Bronchodilators
• Beta-2 Agonists
• Anti-muscarinic Agents
• Corticosteroids
• Combinations
• Miscellaneous
- Antibiotics
- Mucolytics – Acetyl cysteine
- Hypertonic saline
- Other drugs

18. Factors Associated with Non-Compliance in
Asthma and COPD
Medication Usage
 Difficulties associated
with inhalers
 Complicated regimens
 Fears about, or actual
side effects
 Cost
Patient/Physician
 Misunderstanding/lack of
information
 Underestimation of severity
 Attitudes toward ill health
 Cultural factors
 Poor communication

19. Why consider nebulization?
A. Ease of use and technique
B. Effective and reliable drug delivery
C. Fosters patient confidence that drug is reaching
the lungs
D. Patients report positive impact
on health status
E. Use not limited by disease severity
or mental acuity
F. All of the above

20. Use of Jet Nebulizers Can Be as Easy as 1-2-3
(1) Open the vial and
transfer all the medicine
into the nebulizer
medicine cup (reservoir).
(3) Insert mouthpiece and
turn on the compressor.
Breathe as calmly,
deeply, and evenly as
possible until no more
mist is formed in the
nebulizer reservoir.
(2) Connect the nebulizer
reservoir to the
mouthpiece and to
the compressor.
Please see accompanying full Prescribing Information, including Boxed Warning.
Medication Guide: Perforomist® (formoterol fumarate) Inhalation Solution. Napa, CA: Dey Pharma, L.P.; 2008.

21. Function of Jet Nebulizers
1. Air from the compressor breaks
the liquid
medication into small breathable
particles that
form a mist (aerosol).
Adapted from PARI. Jet nebulization technology. http://www.pari.com/pdd/jet-neb-tech.htm.
PARI LC® Reusable Nebulizer
(includes Pari LC® Plus)

22. Function of Jet Nebulizers
1. Air from the compressor
breaks the liquid
medication into small
breathable particles that
form a mist (aerosol).
Adapted from PARI. Jet nebulization technology. http://www.pari.com/pdd/jet-neb-tech.htm.
2. Upon inhalation, the
inspiratory valve at the top
opens, letting air in and
speeding up the generation
of mist to increase flow of
medication to the lungs.
Inspiration
PARI LC® Reusable Nebulizer
(includes Pari LC® Plus)

23. Function of Jet Nebulizers
1. Air from the compressor
breaks the liquid
medication into small
breathable particles that
form a mist (aerosol).
Adapted from PARI. Jet nebulization technology. http://www.pari.com/pdd/jet-neb-tech.htm.
2. Upon inhalation, the
inspiratory valve at the top
opens, letting air in and
speeding up the generation
of mist to increase flow of
medication to the lungs.
3. Upon exhalation, the inspiratory
valve closes, slowing down
the mist; the mouthpiece flap
opens, directing the patient’s
breath away from the nebulizer.
Inspiration
Expiration
PARI LC® Reusable Nebulizer
(includes Pari LC® Plus)

24. Nebulization Delivers Effective Dose
Austitz H et al. Chest. 1989;96:1287.
0
0.2
0.4
0.6
0.8
1.0
Mean
change
in
FEV
1
Cumulative dose (mg)
Nebulizer
0.25 1.0 2.5 10 40
MDI
Cumulative Dose Study
• Multiple inhalations
from MDI are required
to achieve the same
amount
of bronchodilation as
from larger nebulized
dose

25. Nebulization May
Reduce Technique Errors

26. MDIs Are Frequently Associated
With Technique-Related Errors
Incorrect inhalation technique can diminish clinical efficacy of devices1
MDI technique involves 9 steps. Two commonly associated
technique-related errors are1:
Step 5: Place the inhaler mouthpiece
between the lips
(and the teeth); keep the tongue from
obstructing the mouthpiece1
Step 6: Trigger the inhaler while
breathing in deeply and slowly
(this should be about 30 L/min)1
• Unable to coordinate actuation with inspiration (this is common in elderly patients
with impaired dexterity or vision)1,2
• Aerosol is released into mouth while patient is inhaling through nose1
1. Broeders M et al; on behalf of the ADMIT Working Group. Prim Care Respir J. 2009;18:76-82;
2. Lavorini F et al. Respir Med. 2008;102:593-604.

27. Most DPI Systems Require a Minimum Inspiratory Capacity to
Generate Adequate Drug Delivery
DPI technique involves 8 steps. Two commonly associated
with technique-related errors are1:
Step 3: Exhale deeply,
away from the mouthpiece1
• Failure to exhale prior to inhaling (may lead to
suboptimal drug deposition in lung)2
Step 5: Inhale deeply
and forcefully1
• Failure to achieve a forceful and rapid
inspiratory flow at start of inhalation  poor
drug release and low lung deposition2
• Common in elderly patients; severe airflow
limitation; cognitive impairment2,3
1. Broeders M et al; on behalf of the ADMIT Working Group. Prim Care Respir J. 2009;18:76-82;
2. Lavorini F et al. Respir Med. 2008;102:593-604; 3. Zarowitz BJ. Geriatr Nurs. 2009;30:45-49.

28. Although pMDIs/DPIs are the first choice of
delivering aerosols, what do patient say…
• 46% of patients using a pMDI and 17% of those
using a DPI rated their device difficult to use.
• 50% of DPI users were ‘unsure’ as to whether
they received any clinical benefit
• 85% of older patients fail to use a spacer
device when it is prescribed.
Age and Ageing 2007; 36: 213–218

29. Part B. Applications and Indications

30. 30
Management of Acute Asthma
• Nebulizers form the main delivery system for most emergency
departments and hospitals in the developed and developing
world
• Widely used because of convenience and less patient
education or cooperation needed
• Inhaler technique problems overcome and do not become an
issue in emergency setting
Assemble
toAdapt

31. 31
First Drug of Choice In Acute Severe Asthma
1) Nebulised steroid
2) Nebulised salbutamol
3) Injectable theophylline
4) Injectable dexamethasone
Nebulized Salbutamol/SABA
Nebulized salbutamol 2.5-5 mg every
20 min for 1hr
Then every 1-4 hours as required
In children half the above dose
Can ALSO use Levosalbutamol
– less tachycardia
• Consider adding nebulised ipratropium [SAMA]
bromide to SABA
Adults:
• 250 – 500 mcg every 4 to 6 hours
• Even safe to give every 20 – 30 mins for the first 2
hours in a severe attack.
• Also can use combination respule
(SABA+SAMA)
Assemble
toAdapt

32. GC: 72 years construction worker
• Dyspnea over 4 years
• Off and on bouts of cough and phlegm; winter
exacerbations
• “Unable to do anything”
• Smoked > 30 pks/ years
• Tried to use MDIs and DPIs – not able to take
medications due to tremor
• Physical exam: Decreased breath sounds, no wheezes
• BMI: 28 kg/m2 mMRC: 3 6MWD: 328m
FEV1 = 1.91 L 49% predicted BODE = 2

33. What are his treatment alternatives ?
A. Continue to try with different DPI device
B. Use MDI – HFA with spacers only
C. Consider nebulized therapy
D. Don’t treat his disease is not too bad

34. Devices for treatment of airway disease
A large number of different inhaled products
of more than 20 ingredients
……and many more
to come

35. The Use of Inhaled Delivery Devices
• Age is a major factor that determines correct
use of inhaler devices secondary to
decreased muscle strength, memory
problems and loss of coordination

36. Mishandling of Inhaler Devices based on
patients age
Molimard M et al. J Aerosol Med 2003; 16: 249 - 254
Frequency of Critical Errors by Device
n = 3811

37. The older the patients
• Significantly poorer device technique than
younger adults.
• Inadequate technique was high at baseline,
(81% demonstrating at least one observed error)
• Correct device technique was associated with
the type of device used
• Clear statistical improvement was observed with
the active education vs. passive.
Primary Care Respiratory Medicine (2014) 24, 14034;
doi:10.1038/npjpcrm.2014.34;
published online 4 September 2014

38. Technique deteriorate if it is not revisited
• Device education among older COPD patients
often neglected
• Written information, even in pictorial form,
insufficient to achieve improved inhaler use
• Acquisition and initial retention of acceptable
technique is reduced (those with a measurable
cognitive deficit)
Primary Care Respiratory Medicine (2014) 24, 14034;
doi:10.1038/npjpcrm.2014.34;
published online 4 September 2014

39. PIFR and DPI Use
Air Trapping
•Muscle weakness and
air trapping may
decrease ability to
generate minimal
required PIFR (20-30
L/min) when using a
DPI
Weiner P, Weiner M. Respiration. 2006;73:151-156.

40. In elderly patients the ability to generate sufficient
inspiratory flow across a DPI is compromised,
irrespective of the presence of COPD
Eur Respir J 2008; 31: 78–83

41. What are the consequences of Poor MDI/DPI
Technique ?
A. Overuse of medication
B. Wasted medication
C. Lung deposition substantially reduced
D. Overall suboptimal therapy
E. None of the above
F. All of the above

42. Adherence to inhaled medication is significantly
associated with reduced risk of death and
admission to hospital due to exacerbations in COPD
Thorax 2009;64:939–943
3-year trial of inhaled
medications in patients with
moderate to severe COPD

43. Medication delivery: is use nebulize
devices an appropriate alternative ?
Eur Respir Rev 2005; 14: 96, 97–101

44. How to translate the benefits of
new medicines into health gain
for individuals?
• Adherence is defined as the extent to which
a patient’s behavior matches the agreed
recommendations from the prescriber.
• Between 20 and 30 % of prescribed medication
is not taken as recommended?
Report for the National Co-ordinating Centre for NHS
Service Delivery and Organisation R & D (NCCSDO)
December 2005
Med Care 2004, 42:200–209.

45. Efficacy and Safety of Nebulization
for Maintenance Treatment of COPD

46. • Patients using combined nebulizer therapy morning and night with mid-
day use of inhaler device had the most statistically significant
improvements in quality of life indices.
• Concomitant regimen provides the additional symptom relief offered by
a nebulizer with the convenience of an inhaler when patients are away
from home

47. 1 2 3 6 9 12
1.6
1.5
1.4
1.3
1.2
Formoterol Delivered by Nebulizer is as Efficacious as
that Delivered by DPI
Hours
Minutes Hours
Minutes
Day 1 Week 12
Mean
FEV
1
(L)
Mean
FEV
1
(
L)
ITT Population
Gross NJ et al. Respir Med. 2008;102;189-197.
Neb 20 µg (n=123) Aerolizer12 µg (n=114) Placebo (n=114)
1 2 3 6 9 12
1.6
1.5
1.4
1.3
1.2

48. Arformoterol Nebulized Solution vs Salmeterol MDI: Mean %
Change in Morning Predose FEV1
0
5
10
15
20
25
30
Mean
change
in
FEV
1
from
baseline
(%)
Time
6% (Placebo)
18% (Arformoterol)
P<.001
0 24
2 4 6 8 10 12 22
Averaged Over 3 Visits: Weeks 0, 6, and 12
Dose 1
(8 AM)
Dose 2
(8 PM)
Morning
predose
(8 AM)
Placebo
Arformoterol 15 g bid
Salmeterol 42 g bid
Baumgartner RA et al. Clin Ther. 2007;29:261-278.

49. Formoterol Nebulization Solution Plus Tiotropium
Handihaler
Mean FEV1 on Day 1 and at Week 6
* Tolerance to the effects of inhaled 2-agonists can occur with regularly scheduled, chronic use.
† P≤0.0003 vs placebo/tiotropium.
Hanania NA et al. Drugs 2009
Formoterol Solution/Tiotropium Day 1
Placebo/Tiotropium Day 1
Placebo/Tiotropium Week 6
Formoterol Solution/ Tiotropium Week 6
FEV
1
(L)
1.7
1.3
1.2
1.1
1.0
1.4
1.5
1.6
†
†
† †
† †
†
†
† † †
0.5 1.0 1.5 2.0 2.5 3.0
5
(min)
Pre-
dose
Postdose (hours)

50. Significant (≥4 Units) Improvements
in Total St. George’s Respiratory Questionnaire (SGRQ) Score vs Placebo
Adapted from Gross NJ et al. Respir Med. 2008;102:189-197; Data on file. Dey Pharma, L.P.
Improvement
Formoterol Solution (n=123)
Placebo (n=114)
*P≤.03 vs placebo.
Mean change in SGRQ score from baseline
Activity
score
2 0 -2 -4 -6 -8 -10 -12
Symptom
score
*
Impact
score
*
-5.6
Total
score
-0.7
-8.7
-3.0
-4.8
-1.4
-4.6
+0.8
A change in
total score
of 4 units
is clinically
relevant
*

51. Formoterol Solution Plus Tiotropium:
Effect on Dyspnea (TDI) and Health Status
(SGRQ) – Responder Analysis
SGRQ=St. George’s Respiratory Questionnaire; TDI=transition dyspnea index.
Hanania NA et al. Drugs 2009
Responder
categorization
(%)
10
20
30
40
50
70
FormoterolSolution/Tiotropium
(n=78)
Placebo/Tiotropium
(n=77)
Responder
categorization
(%) 10
30
40
50
60
70
58.4
47.2
60
20
61.0
25.0
Dyspnea improvement
(TDI ≥1)
Health status improvement
(change in total
SGRQ score ≥4 units)
0 0

52. Rescue Albuterol Use Over 12 Weeks
* P≤.0003 vs placebo.
Adapted from Gross NJ et al. Respir Med. 2008;102:189-197, with permission from Elsevier;
Data on file. Dey Pharma, L.P.
Screening to
Day 1
Day 1 to
Week 4
3.0
2.5
Puffs
per
day
Formoterol Inhalation
Solution (n=123)
Placebo
(n=114)
2.0
1.5
1.0
0.5
0
Week 4 to
Week 8
Week 8 to
Week 12
*
* *
2.82 2.80
1.63
2.86
1.53
2.91
1.50
2.71 Albuterol
use
decreased
by
42%

53. Nebulized Arformoterol : Incidence and Risk of COPD
Exacerbations
Hanania NA et al. CHEST 2013

54. Overall Incidence of Adverse Events*
Adverse Event (AE), n (%)
Formoterol
Inhalation Solution
(n=123)
Placebo
(n=114)
Diarrhea 6 (4.9) 4 (3.5)
Nausea 6 (4.9) 3 (2.6)
Nasopharyngitis 4 (3.3) 2 (1.8)
Dry mouth 4 (3.3) 2 (1.8)
Vomiting 3 (2.4) 2 (1.8)
Dizziness 3 (2.4) 1 (0.9)
Insomnia 3 (2.4) 0
* Treatment-emergent adverse events (incidence ≥2% and greater than placebo).
† ≥1% of Perforomist® Inhalation Solution participants and with a frequency greater than placebo.
Adapted from Gross NJ et al. Respir Med. 2008;102:189-197,
• Overall incidence: 51.2% (Formoterol Inhalation Solution); 57.0% (placebo).
COPD exacerbation: 4.1% (Formoterol Inhalation Solution); 7.9% (placebo).
Serious AEs: 0.8% (Formoterol Inhalation Solution); 4.4% (placebo)

55. Very Severe COPD: Formoterol/Budesonide Neb vs pMDI –
PrB FeV1
Gogtay et al APSR 2014, NAPCON 2014

56. For the patient point of view:
What are the most positive aspects of chronic
nebulization therapy?
a. Enables one to breathe easier/opens up
airways
b. Quick relief / fast acting
c. Able to do more activities
d. Live life more normally
e. All of the Above
f. None of the Above

57. NEB Survey Data Support Patient Satisfaction With
Nebulization
You can
breathe easier*
You can be more
physically active
in your daily life*
The benefits of nebulization
outweigh any difficulties
or inconveniences
Total
patient
responses
(%)
91
74
79
5
21
12
0
10
20
30
40
50
60
70
80
90
100 Agree
Disagree
* These benefits translated across all age groups (<45 years, 45-64, and 65 years) and stages of
patient-reported disease severity (not severe and severe). N=400 adults. NEB=Nebulization for Easier
Breathing.).
Patients with COPD responded positively to statements
regarding the perceived efficacy of nebulization
COPD 2013; 10:482–492

58. 0
20
40
60
80
100
NEB Survey: The Majority of Caregivers Recognized the Benefits
of Nebulization and Its Positive Impact on Their Patients’ Quality
of Life
* Percentages are based on rounding and reflect only patients who responded to the given statement.
n=400 caregivers.
NEB=Nebulization for Easier Breathing.
Nebulization has made
it easier to help care for
friend/family member
The benefits
outweigh any
difficulties or
inconveniences
The overall quality of life
of my friend/family
member has improved since
beginning nebulization
Total
patient
responses
*
(%)
86 85 82
9 10 14
Agree
Disagree
COPD 2013; 10:482–492

59. Clinical Scenarios Where Maintenance Nebulization
is Preferred in Patients With COPD
• Cognitive impairment that
precludes effective use of
handheld inhalers
• Impaired manual dexterity due
to arthritis, neurological
alterations, or stroke
• Severe pain or muscle
weakness due to
neuromuscular disease
• Patient preference for
nebulizers
• Failure to comply with the use
of pMDIs and DPIs
• When multiple agents need to
be co-administered
• Insufficient inspiratory capacity
to use DPIs
• Unable to use pMDIs or DPIs
in an optimal manner despite
adequate instruction and
training which may result in
inadequate symptom relief
Dhand R et al. COPD. 2012;9:58-72.

60. Maintenance Therapy – Stable COPD
• If patients with stable COPD experience greater symptomatic benefit
with nebulizers, then withholding nebulizer therapy from
those patients may be denying them the ability to better control their
symptoms, reduce acute exacerbations, and enhance their quality of
life. We recommend well-designed comparative efficacy and safety
trials with LABA/LAMA combinations, with or without ICS,
administered by inhalers versus nebulizers to evaluate the role of
nebulizers for maintenance therapy in patients with stable COPD.
Terry PD, Dhand R. Maintenance Therapy with Nebulizers in Patients with Stable COPD: Need for
Reevaluation. Pulm Therapy 2020; 6(2): 177–192

61. Overview: Mucus-Quantity/Quality
Cough or
air flow
Mucus
gland
Mucus
flow
Surfactant
layer
Mucus
gland
Int J Chron Obstruct Pulmon Dis. 2014;

62. Excessive mucus production
and associated complications
N Engl J Med. 2010 Dec 2; 363(23): 2233

63. Mucus
hypersecretion
plays an important
role and is an
important
pathophysiological
and clinical
manifestation of
the following
airway
diseases……
ACUTE
BRONCHIOLITIS
BRONCHIEC-
TASIS
CYSTIC
FIBROSIS

64. Treatment Options for Airway
mucus clearance
Airway clearance
therapy
Breathing
techniques
Autogenic
drainage
Mechanical
devices
Pharmacological-
Mucoactives
Expecto
rants-
Hyperto
nic
Saline
Mucoregu
lators-
Carbocyst
eine and
macrolides
Mucolytics-
NAC, dornase
alpha, etc.
Mucokine
tics-
Bronchodil
ators,
ambroxol.
International journal of chronic obstructive pulmonary disease 13 (2018): 399.

65. Conditions where Nebulizers must be used
1. Drugs which can be delivered only by the Nebulizer route
2. Acute exacerbations of asthma or COPD requiring hospitalization.
3. Altered mental state/cognitive decline/confused state
4. Patients who are inadequately controlled on DPIs or MDIs needing high doses of
inhaled bronchodilators or corticosteroids
5. Lack of coordination while using pMDI despite best efforts to train
6. Visual factors that may limit ability to use DPI’s and pMDI’s such as Macular
degeneration, Cataracts, or Glaucoma.
7. Dexterity issues such as parkinsonism or stroke
8. Hand arthritis in elderly patients (the use of pMDI or DPI use should be encouraged if
assisted inhalation for pMDI or DPI is possible
9. Non-CF Bronchiectasis in patients requiring inhaled antibiotics
10. Bronchiolitis in patients requiring inhaled therapy
11. Cystic Fibrosis (Antibiotics and mucolytics)
12. Pulmonary arterial hypertension requiring inhaled therapy

66. Drugs only by the Nebulized Route
• Antibiotics: Tobramycin, Colistin, Amikacin, Fosfomycin,
Pentamidine, Fuoroquinolones
• Mucolytics: Dornase alpha, N-Acetyl Cysteine, Hypertonic Saline
• Bronchodilators: Salbutamol, Levosalbutamol, Ipratropium,
Salbutamol-Ipratropium, Terbutaline, Formoterol, Ar-Formoterol,
Glycopyrronium, Glycopyrronium-Formoterol
• Corticosteroids: Budesonide (*should be avoided with the
ultrasonic nebulizer) (Bronchodilators and steroids can also
be given by MDI or DPI inhalers)
• Others: Interferon beta, Immunomodulators: Mycobacterium
Vaccae (to treat COVID-19), PDE-3 inhibitor: Enoximone, Surfactant

67. Scoring for
Nebulization
indication in Primary
Care
Jindal SK, Pawar S, Hasan
A,Ghoshal A,Dhar R, K Katiyar SK,
Satish KS,Talwar D, Salvi S.
Scoring System for the Use of
Nebulizers in the Primary Care
Settings: An Expert Consensus
Statement. Journal of the
Association of Physicians of India
(2023): 10.5005/japi-11001-0273

68. SUMMARY
• Nebulization is the most efficient and convenient form
of inhalation therapy for acute asthma, exacerbation of
COPD and other conditions where use of MDIs and DPIs
is not possible.
• Nebulization is the only mode to administer certain
drugs for which inhalers are not available.
• Domiciliary nebulization is indicated as maintenance
therapy of COPD for certain categories of patients.
• A simple scoring method is now available to decide in
whom to give nebulized treatment for use in the primary
care settings with limited resources.

69. THANK YOU