Frimley Guidelines

Nebuliser Doses and Devices

Key Points

  • This guideline describes the administration of nebulised medications used in respiratory diseases such as Cystic Fibrosis and bronchiectasis.

  • Included in the table are recommended doses, cautions, appropriate nebuliser devices and potential side effects.

  • Medications are listed alphabetically by generic drug name, but prescribing should be brand specific due to the specific administration instructions for each formulation.

Version:3
Date Issued:14 June 2024
Review Date:July 2026
Key words:Nebules, nebulised, nebuliser, cystic fibrosis, bronchiectasis, pharmacy, physiotherapy, medication.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Administration of nebulised medication

  • Minimum fill level dependent on residual volume in nebuliser

  • Usual fill level 2-4ml

  • Use mouthpiece whenever possible to avoid medication getting in the eyes.

  • Diluent sodium chloride 0.9% unless otherwise stated.

  • Water for injection should not be used as a diluent (unless specified) as it induces bronchospasm.

  • Where compatibility is stated, this is for two medications only (excluding sodium chloride 0.9%). This practice is generally unlicensed.

  • Mixing of three medications cannot be recommended

For antibiotic nebulisers:

administer in a well-ventilated room, tubing outside the window or filter sets should be used to prevent waste aerosol from entering the environment for all nebuliser devices except an i-Neb.

Inhaled antibiotics should always be taken after airway clearance.

The information in this table is for guidance only. Consult BNF for comprehensive list of side effects for licensed nebulised medication.


Drug

(Brand name)

Action
Nebuliser requirements 		   
Dose/Frequency   
Directions for dilution and suitable
diluent 		   
Precautions/comments   		   
Side Effects   

Acetylcysteine injection
(Parvolex®)

Mucolytic
Nebuliser to be driven by compressed air ONLY.
(Oxygen inactivates acetylcysteine). DO NOT
use nebulisers containing iron, copper or rubber
components.
3-5ml of 20% solution
TDS-QDS.
May be used undiluted, or may be
further diluted with sodium chloride 0.9%
Unlicensed use

Oxygen causes degradation
of acetylcysteine
Unpleasant odour
Sticky residue
Bronchospasm: If this occurs
1ml of the 20% solution can be
diluted with 5ml sodium chloride
0.9%. Nebulise 3-4ml of the
diluted solution

Adrenaline 1 in
1000 (1mg/ml) solution

Bronchodilator/
Local vasoconstriction
Driven by air (6 Litres per min) over 15minutes.
1-5mg (i.e., 1-5ml)
Max frequency
2- 4 hourly
Dilute 0.5ml - 5ml adrenaline with 5ml
sodium chloride 0.9%
Unlicensed use

Stridor, croup, haemorrhage

Repeated treatment can cause
rebound tissue oedema, symptoms
may become worse after action has
subsided.

Anxiety, tremor, tachycardia,
arrhythmias and headache
Inhalation of adrenaline has
been associated with epigastric
pain, attributed to ingestion of
some of the inhalation; minimise
by rinsing the mouth and throat
with water after inhaling.

Amikacin

Antibiotic

Nebulise through PARI LC plus
500mg BD

Must be Hospira
brand
Can be further diluted with sodium chloride
0.9% if needed to enhance tolerability.
Unlicensed use of the IV solution.

Test dose required.
Risk of bronchospasm & haemoptysis
mouth ulcers, cough.
Monitor renal function before treatment
and then annually if continued


Drug

(Brand name)

Action 		   
Nebuliser requirements   		   
Dose/Frequency   
Directions for dilution and suitable
diluent 		   
Precautions/comments   		   
Side Effects   

Liposomal Amikacin

(Arikayce®)

Antibiotic
Nebulise through E-flow and
use Lamira handset provided
590mg in 8mL OD
Do not dilute
Unlicensed, apply for
compassionate use.

Test dose required.

Should be refrigerated.
Allow to get to room
temperature prior to
administration.
Risk of bronchospasm
& haemoptysis mouth ulcers,
cough.

Monitor renal function before
treatment and then annually
if continued

Liposomal Amphotericin B
(AmBisome®)

Antifungal
PARI LC plus neb required.


25mg BD
Reconstitute 50mg vial with 12ml
water for injection, each vial should
be shaken vigorously for 1 – 2 minutes,
the preparation will froth and should be
allowed to stand then withdraw 6ml (25mg).
Store in the fridge.
Unlicensed use.
Unlicensed use of
AmBisome. Respiratory
function tests should be
performed before & after
administration. Stable for
24 hours at 2 – 8oC once
reconstituted.

Test dose required.
Bronchospasm - Consider bronchodilator
before.


Drug

(Brand name)

Action 		   
Nebuliser requirements   		   
Dose/Frequency   
Directions for dilution and suitable
diluent 		   
Precautions/comments   		   
Side Effects   

Aztreonam Lysine (Cayston®)

Antibiotic
Should only be used with
the Altera Nebuliser Handset
and Altera Aerosol Head
(supplied in box) connected
to an eFlow rapid Control Unit.
75mg TDS alternate months
Powder and solvent provided in the product,
after reconstitution use immediately (if not
store in fridge 2 – 8oC and use within 8hours)
Needs pre-dosing with bronchodilator:
short acting bronchodilators to be taken
between 15 minutes and 4 hours and
long-acting bronchodilators to be taken
between 30 minutes and 12 hours prior
to each dose.

If on multiple inhaled therapies,
recommended order; (1) bronchodilator,
(2) mucolytic, (3) aztreonam last.

Refrigeration of powder and solution required
2 – 8oC but may remain below 25oC for up
to 28 days.

Test dose required.

Wheezing, bronchospasm,
cough, haemoptysis, pyrexia,
arthralgia, rash, rhinorrhoea,
pharyngolaryngeal pain


Drug

(Brand name)

Action 		   
Nebuliser requirements   		   
Dose/Frequency   
Directions for dilution and suitable
diluent 		   
Precautions/comments   		   
Side Effects   

Budesonide respules
(Pulmicort®)

Corticosteroid
Use Pari LC plus or sidestream
equipped with a mouthpiece or
suitable face mask. Use air-flow
rate of 6 – 8 Litres per min.
1-2mg BD
Maintenance:
0.5-1mg BD

(Administer within 30
mins)
Shake Respule gently and open by
twisting off the wing tab. The contents
of the Respule should be gently
squeezed into the nebuliser cup.

If less than 2ml of suspension is used,
the remaining suspension must be
discarded (as not sterile).
Pulmicort respules can be mixed
with 0.9% sodium chloride and with
solutions for nebulisation of terbutaline,
salbutamol, acetylcysteine, or
ipratropium bromide.
Risk of paradoxical
bronchospasm.

Mild bronchospasm:
Pre-treat with nebulisation
of bronchodilator.

Rinse mouth with water after
use to reduce risk of oral candidiasis.

Throat irritation (hoarseness)

Ceftazidime injection

Antibiotic
Use PARI LC plus
1g BD
Dilute 1g with 3ml water for injection
Unlicensed use

Test dose required.

Bronchospasm: Pre-treat with
bronchodilator.
Tastes awful.


Drug

(Brand name)

Action 		   
Nebuliser requirements   		   
Dose/Frequency   
Directions for dilution and suitable
diluent 		   
Precautions/comments   
Side Effects

Colistimethate sodium
First-Line:
Colomycin®

Antibiotic
Use PARI LC plus
or E-flow

500,000 units –
2 mega units
BD to TDS
Reconstitute 1 MU with 3ml or 2 MU
with 4ml sodium chloride 0.9%
(first line) or water for injection

Compatible with salbutamol or
gentamicin (used as the diluent).
Stable for 24 hours at 2 – 8oC
once reconstituted.

Test dose required.

Inhalation may induce coughing
or bronchospasm.
Bronchospasm can be reduced by
(1) diluting with water, (2) pre-dose
with bronchodilator. Sore throat/mouth
may be due to Candida albicans
infection or hypersensitivity. Skin rash
may also indicate hypersensitivity,
if this occurs treatment should be
withdrawn.

Colistimethate sodium

Second-Line:
Promixin®

Antibiotic
Via I-Neb
Use grey chamber

PARI LC plus
1,000,000 units –
2,000,000 units
BD to TDS
Each vial reconstituted with a minimum
of 1mL Water for Injections (hypotonic)
or a 50:50 mixture of water for injection
and 0.9% sodium chloride (isotonic) or
0.9% sodium chloride (hypertonic) to
produce a clear colourless to pale
yellow solution.
For an I-Neb use 1mL
For PARI LC plus use 3mL
Compatible with salbutamol or
gentamicin (used as the diluent).

If not used immediately
after reconstitution may
be used within 24 hours if stored in
refrigerator (2-8oC).

Test dose required.

Refer patient to Bionical to supply
i-Neb
Inhalation may induce coughing or
bronchospasm. Bronchospasm
can be reduced by (1) diluting with
water, (2) pre-dose with bronchodilator.

Sore throat/mouth may be due to Candida
albicans infection or hypersensitivity.
Skin rash may also indicate hypersensitivity,
if this occurs treatment should be withdrawn.

Dornase Alfa (Pulmozyme®)



Mucolytic
Use through Sidestream,
PARI LC plus, E-flow or i-Neb

With i-Neb use green chamber
and 1mL to get equivalent to
2.5mg dose.


2.5mg (2,500
units) OD to max
5mg BD
DO NOT mix with other drugs.
Use 30-60mins prior to physiotherapy,
unless otherwise instructed.
Store in a refrigerator (2°C - 8°C).

Keep the ampoule in the outer
carton in order to protect from light.

A single brief exposure to elevated
temperatures (less than or equal to
24 hours at up to 30°C) does not
affect product stability.

Test dose required.
Pharyngitis, voice changes, chest pain
Occasionally: laryngitis, rashes, urticaria,
conjunctivitis


Drug

(Brand name)

Action 		   
Nebuliser requirements   		   
Dose/Frequency   
Directions for dilution and suitable
diluent 		   
Precautions/comments   		   
Side Effects   

Fluticasone nebules
(Flixotide®)

Corticosteroid

Licensed product
discontinued
Use through Sidestream or
PARI LC plus.

Via mouthpiece, don’t use
facemask (if possible).
0.5-2mg BD
May dilute further with sodium chloride
0.9%, to aid administration of small
volumes or if prolonged delivery time
is desired.
Risk of adrenal suppression with
long term high dose use: issue
steroid card
Risk of paradoxical
bronchospasm.

Mild bronchospasm: nebulise
a bronchodilator prior to administration
of fluticasone.

Oral candidiasis:
rinse mouth with water after use
to reduce risk.

Throat irritation (hoarseness).

Atrophic changes to facial skin may
occur on prolonged use with a facemask
(protect exposed skin with barrier cream,
or thoroughly wash face afterwards).

Gentamicin

Antibiotic
Use PARI-LC plus
80mg – 160mg BD
Dilute with up to 4ml sodium chloride 0.9%

Minimum neb volume is 3 ml
Unlicensed use
Compatible with Colistin.
Blood levels not necessary.

Test dose required.
Sore mouth, sore throat, cough
& bronchospasm


Drug

(Brand name)

Action 		   
Nebuliser requirements   		   
Dose/Frequency   
Directions for dilution and suitable
diluent 		   
Precautions/comments   		   
Side Effects   

Ipratropium
(Atrovent®)
Antimuscarinic

Bronchodilator
Use sidestream,
PARI-LC plus or
E-Flow
250-500micrograms TDS - QDS
or repeated as necessary
May be further diluted with sodium
chloride 0.9% if necessary.
Use with caution in patients with prostatic
hyperplasia, bladder outflow obstruction &
those susceptible to angle-closure glaucoma
(use mouthpiece with nebuliser)

Compatible with budesonide, salbutamol,
terbutaline.
Dry mouth, constipation,
nausea, and headache.
Rarely urinary retention.

Levofloxacin
(Quinsair®)

Antibiotic
Use Zirela nebuliser
system with e-flow
Alternate months

240mg BD (ideally
12 hours apart +/- 4 hours)

Test dose required.

Homecare will supply filter
sets and pads
Bitter taste. Significant systemic
absorption therefore risk of
convulsions, tendon damage
etc.

Risk of bronchospasm.

Meropenem

Antibiotic
Use PARI-LC plus
250mg BD
Reconstitute 500mg vial with 10ml sodium
chloride 0.9%. Withdraw 5ml to nebulise,
ignore displacement value. Keep remainder
of vial in fridge for up to 18 hours.
Unlicensed use

Test dose required.


Drug

(Brand name)

Action 		   
Nebuliser requirements   		   
Dose/Frequency   
Directions for dilution and suitable
diluent 		   
Precautions/comments   		   
Side Effects   

Salbutamol
(Ventolin®)

Bronchodilator
Use through Sidestream,
PARI LC plus, E-flow or
i-Neb

For i-Neb use grey
chamber
2.5mg in 2.5ml PRN
5mg in 2.5ml PRN

Up to 40mg may be given
under strict medical supervision
in hospital.

Patients requiring back-to-back
nebuliser should be reviewed regularly.
Can be used undiluted, however
if prolonged delivery time (more
than 10minutes) is required, may
be diluted with sodium chloride
0.9%
Compatible with; budesonide,
fluticasone, ipratropium, sodium
chloride 0.9%, (if mixing with
colistimethate ensure salbutamol
is preservative-free).
Paradoxical bronchospasm.
Fine tremor, hypokalaemia,
nervous tension, headache,
muscle cramps, palpitations,
tachycardia

Sodium chloride 0.9%

Mucolytic
Use through Sidestream,
PARI LC plus or E-flow
5ml PRN
(Up to 2 hourly)

Preferred diluent for other medications,
unless otherwise stated.
Bronchospasm: Use with or after
bronchodilator to reduce effect

Sodium chloride 3%

Mucolytic

Use if 7% not tolerated
Use through Sidestream,
PARI LC plus, E-flow or i-Neb

For i-Neb use lilac chamber
and nebulise twice
4ml BD
(Up to QDS)
Further dilution not required.
For use only in:
cystic fibrosis;
bronchiectasis;
may consider in sputum
retention.
Usage should be advised
by a Respiratory physician
or physiotherapist.

Test dose required.

Bronchospasm: Use with or after
bronchodilator to reduce effect
Nausea.

Patient should have salbutamol
nebules prescribed on drug chart
(at least on the ‘PRN’ section).


Drug

(Brand name)

Action 		   
Nebuliser requirements   		   
Dose/Frequency   
Directions for dilution and suitable
diluent 		   
Precautions/comments   		   
Side Effects   

Sodium chloride 7%

Mucolytic
Use through Sidestream,
PARI LC plus, E-flow or
i-Neb

For i-Neb use lilac chamber
and nebulise twice
4ml BD
(Up to QDS)
Further dilution not required.
For use only in:

cystic fibrosis;

bronchiectasis;

may consider in sputum retention.

Usage should be advised by a
Respiratory physician or
physiotherapist.

Test dose required.
Bronchospasm: Use
with or after bronchodilator
to reduce effect Nausea.

Patient should have salbutamol
nebules prescribed on drug chart
(at least on the ‘PRN’ section).

Terbutaline Respules (Bricanyl®)

Second Line Beta-agonist

Bronchodilator
Use through Sidestream,
PARI LC plus or E-flow
5-10mg BD-QDS
additional doses may
be given if necessary
Further dilution not normally
required at recommended
doses.

Use sodium chloride 0.9%
if dilution required.
Compatible with sodium chloride
0.9%, budesonide, fluticasone,
ipratropium.
Paradoxical bronchospasm.
Fine tremor, nervous tension,
headache, muscle cramps,
palpitations, tachycardia

Tobramycin

First line for new patients:
Vantobra®

Antibiotic
Use through E-flow and
Tolero nebuliser handset
supplied
Alternate months

170mg BD (dose
interval as close as
possible to 12hours,
not less than 6 hours)
No further dilution required.

DO NOT mix with other drugs.
Should be stored in a fridge,
however, may be stored at up
to 25oC for maximum of
28 days.

Test dose required.
Risk of bronchospasm &
haemoptysis Mouth ulcers,
voice alteration, cough Monitor
renal function before treatment
and then annually if continued

   
Drug
   
(Brand   name)
   
Action   		   
Nebuliser requirements   		   
Dose/Frequency   
Directions for dilution and suitable
diluent 		   
Precautions/comments   		   
Side Effects   

Tobramycin

First line for established
patients: Bramitob®

Antibiotic
Use through PARI
LC plus, E-flow or
i-neb

For i-neb: use lilac
chamber 2.5mL twice.
Alternate months

300mg BD (dose
interval as close as
possible to 12 hours)
No further dilution required.

DO NOT mix with other drugs.
Store in a fridge at 2-8oC Bramitob
bags (intact or opened) may be stored
for up to 3 months at not more than
25oC.

Test dose required.

Homecare will provide filter set
and pads
Risk of bronchospasm &
haemoptysis
Mouth ulcers, voice alteration,
cough

Monitor renal function before
treatment and then annually
if continued

Tobramycin

Second line:
TOBI®

Antibiotic
Use i-neb

Use lilac chamber
2.5ml twice
Alternate months

300mg BD (dose
interval as close as
possible to 12hours,
not less than 6 hours)
No further dilution required.

DO NOT mix with other drugs.
Should be stored in a fridge, however,
may be stored at up to 25oC for
maximum of 28 days.

Test dose required.
Risk of bronchospasm &
haemoptysis
Mouth ulcers, voice alteration,
cough

Monitor renal function before
treatment and then annually
if continued

Vancomycin

Antibiotic
Use PARI LC Plus
or E-flow
250mg BD
Reconstitute 500mg vial with
10ml water for injection.
Withdraw 5ml to nebulise, ignore
displacement value. Keep
remainder of vial in fridge
for up to 24 hr.
Unlicensed use.

Use bronchodilator prior to use.

Test dose required.
Risk of bronchospasm.