Nebulisation of Solution for Inhalation

Availability solution for inhalation

• Salbutamol 5mg/ml (10ml)
• Ipratropium bromide  0.25mg/ml
• Budesonide 0.5mg/ml (2ml)

General Information

• Treatment should be given using either an electrical compressor or compressed air. In acute severe asthma, oxygen as prescribed should beused as the driving gas whenever possible (BTS/SIGN, 2011).
• The volume of fluid in the nebuliser chamber is usually 2-4.5mls, although this may vary depending on the drug to be administered.
• Bronchodilators such as salbutamol (2.5mls) and ipratropium bromide (2mls) may be combined to make up to 4.5mls.
• The normal nebulising time is approximately 5-10 minutes. However, owing to the viscosity of antibiotics and steroids, nebulising time may need to be increased
• Bronchodilator responses are the same whether a mask or a mouthpiece is used. Face masks are better for children and for emergencies.
• Mouthpieces are recommended when steroids, antibiotics or antimuscarinic bronchodilators (anticholinergics) are being nebulised. If a face mask is used, it should be close fitting and not held away from the face (BTS, 2011).
• Antimuscarinic bronchodilators such as ipratropium bromide cause/exacerbate glaucoma, particularly when given with nebulised salbutamol (and possibly other β2 agonists) (BNF, 2011). Therefore, a mouthpiece should be used.
• Nebulisers just before meals may spoil an already small appetite, but other patients who are severely breathless may need the bronchodilation to give them breath to eat.
• Where the drug to be nebulised requires dilution, the diluent should be 0.9% sodium chloride. Water for injection should not be used as it may cause bronchoconstriction if nebulised
• Oxygen should be used with caution in patients with COPD as some may be vulnerable to episodes of hypercapnic respiratory failure. For this reason oxygen must always be prescribed by a member of the medical staff
• Drugs should only be added to the nebuliser chamber immediately prior to administration, as nebuliser drugs do not contain preservatives

Combivent Inhalation solution

• 0.50mg Ipratropium Bromide + 2.5mg Salbutamol (2.5ml)
• As we do not have the combination product, the solution can be made up using 2ml of ipratropium bromide (0.25mg/ml) and 0.5ml salvutamol (5mg/ml) together with 1.5ml NS

Salbutamol dose:

Adults

• The usual starting dose is 2.5mg as a single dose. This may be increased to 5mg. Treatment may be repeated up to four times a day.
• For the treatment of severe airways obstruction in adult hospitalised patients, higher doses up to 40mg per day can be given under strict medical supervision.

Pediatric

• Children aged 12 years and over: Dose as per adult population.
• Children aged 4 to 11 years: 2.5mg to 5mg up to four times a day.
• Clinical efficacy of nebulised salbutamol in infants under 18 months is uncertain. As transient hypoxaemia may occur, supplemental oxygen therapy should be considered.

Overdosage

• The effects of overdosage are expected to be related primarily to salbutamol because acute overdosage with ipratropium bromide is unlikely since ipratropium bromide is not well absorbed systemically after aerosol or oral administration
• The expected symptoms with salbutamol overdosage are those of excessive beta-adrenergic stimulation, such as: tachycardia, palpitations, tremor, cardiac arrhythmia, hypokalemia, hypertension, hypotension, widening of pulse pressure, anginal pain, flushing and, in extreme cases, sudden death.
• Lactic acidosis has been reported in association with high therapeutic doses as well as overdoses of short-acting beta-agonist therapy, therefore monitoring for elevated serum lactate and consequent metabolic acidosis (particularly if there is persistence or worsening of tachypnea despite resolution of other signs of bronchospasm such as wheezing) may be indicated in the setting of overdose

References:

1. Combivent PRODUCT MONOGRAPH
2. Nottingham University Hospitals NHS Trust
3. https://www.medicines.org.uk/emc/medicine/27928