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European Respiratory Society Guidelines on the use of nebulizers

J. Boe, J.H. Dennis, B.R. O'Driscoll, T.T. Bauer, M. Carone, B. Dautzenberg, P. Diot, K. Heslop, L. Lannefors
European Respiratory Journal 2001 18: 228-242; DOI:
J. Boe
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J.H. Dennis
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B.R. O'Driscoll
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T.T. Bauer
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M. Carone
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B. Dautzenberg
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P. Diot
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K. Heslop
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L. Lannefors
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  • Article
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  • Fig. 1.—
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    Fig. 1.—

    Relationship between aerosol aerodynamic diameter and deposition in the healthy adult lung (based on in vitro models). ○: total body; □: total lung; ⋄: oropharyngeal; •: central airways; ▪: peripheral airways. Reproduced with permission 5.

  • Fig. 2.—
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    Fig. 2.—

    Schematic of Comité European de Normalisation methodology to measure nebulized aerosol droplet size. A constant inhalation of 15 L·min−1 is drawn over (or through) the nebulizer. Nebulized aerosol containing a NaF solute tracer mixes with the entrained air. A low flow cascade impactor (Marple Series 296/8X) samples aerosol at 2 L·min−1 from this flow, and impacted aerosol can be subsequently desorbed and analysed from each size fraction from which the droplet size distribution can be determined (not to scale).

  • Fig. 3.—
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    Fig. 3.—

    Schematic of Comité European de Normalisation methodology to measure nebulized aerosol output. “Inhaled” aerosol output is subject to sinus flow breath simulation and aerosol is collected onto low resistance electrostatic filters. Aerosol contains trace concentrations of sodium fluoride which can be subsequently desorbed and quantified electrochemically (not to scale). rpm: revolutions per minute.

Tables

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  • Table 1

    Site of action of commonly nebulized drug aerosol therapies and the droplet size thought ideal for maximum clinical benefit

    DrugTarget airway siteSpecial considerations
    β2-agonists acuteCentral-peripheralUse O2 as driving gas unless there are concerns about CO2 retention
    Adults and children
    β2-agonists chronicCentral-peripheralReduce nebulization time for treatment compliance
    Adults and Children
    Anti-cholinergicCentralMouth piece (preferable) or tight sealing face mask
    Adults and Children(Mouth piece for glaucoma patients)
    CorticosteroidCentral-peripheralMinimize skin and eye exposure
    Children and adultsMouthpiece (preferably) (or tightly sealed face mask)
    Amino-glycosides or ColomycinCentral-peripheralMouth piece
    AdultsFilter or exhaust exhaled gases
    Pre-treat with β-agonist when necessary
    PentamidinePeripheralMouth piece
    AdultsPretreat with nebulized β-agonist
    Filter or exhaust exhaled gases
    AmphotericinCentralDilute with water not saline
    AdultsFilter or exhaust exhaled gases
    RhDNaseCentralMouthpiece
    • O2: Oxygen

    • CO2: carbon dioxide

    • RhDNase: recombinant human deoxyribonuclease

  • Table 2

    Parameters to be standardized in the use of nebulizer systems

    Nebulizer type
    Choice of driving gas
    Driving gas pressure
    Driving gas flow rate
    Drug and formulation
    Nebulizer fill volume (as recommended by manufacturer)
    Time of nebulization
    Accessories (Mouthpiece/face mask etc.)
    Residual solute volume (amount of drug left in chamber)
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European Respiratory Society Guidelines on the use of nebulizers
Co-Chairmen of the Task Force:, J. Boe, J.H. Dennis, B.R. O'Driscoll, Members of Task Force:, T.T. Bauer, M. Carone, B. Dautzenberg, P. Diot, K. Heslop, L. Lannefors
European Respiratory Journal Jul 2001, 18 (1) 228-242;

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European Respiratory Society Guidelines on the use of nebulizers
Co-Chairmen of the Task Force:, J. Boe, J.H. Dennis, B.R. O'Driscoll, Members of Task Force:, T.T. Bauer, M. Carone, B. Dautzenberg, P. Diot, K. Heslop, L. Lannefors
European Respiratory Journal Jul 2001, 18 (1) 228-242;
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  • Article
    • Aims of the European Respiratory Society Nebulizer Guidelines and target audience
    • Format and development of European Respiratory Society Nebulizer Guidelines
    • Problems with the scientific background of clinical nebulizer use
    • Responsibilities of manufacturers
    • Responsibilities of prescribers
    • Technical aspects of nebulizer use
    • Clinical uses of nebulizers
    • Use of nebulizers in cystic fibrosis
    • Service issues
    • Implementation and dissemination of the European Respiratory Society Nebulizer Guidelines
    • Areas of uncertainty and future research needs
    • Acknowledgments
    • References
  • Figures & Data
  • Info & Metrics
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