Inhaler nebulizer

1. Nebulized Budesonide (Pulmicort)

• Indications:
  • Chronic Asthma: First-line controller therapy for persistent asthma.
  • Viral-Induced Wheezing (VIW): Reduces exacerbation risk in children ≤5 years.
• Safety:
  • Long-term use (>6 months) requires growth monitoring.
  • Oral candidiasis risk: Advise mouth rinsing post-inhalation (AAP).
• Daily Use:
  • Chronic asthma: 0.25–1 mg/day (age-dependent).
  • VIW: Intermittent high-dose budesonide (1–2 mg q12h) during viral infections is non-inferior to daily therapy.

2. Salbutamol (Ventolin/Farcolin)

• Acute Bronchospasm:
  • Dose: 2.5 mg nebulized q4–6h PRN (max 10 mg/day).
  • Infants <18 months: Off-label but widely used for bronchiolitis; monitor for tachycardia/tremors.
• Device Optimization:
  • MDI + spacer (e.g., AeroChamber) is preferred over nebulizers in children ≥1 year (equivalent efficacy, lower hospitalization time).
  • Nebulizers reserved for severe distress or poor MDI cooperation.
• Avoid Routine Daily Use:
  • 3 SABA doses/week signals poor asthma control; escalate to ICS (GINA 2023).

3. Hypertonic Saline (3% NaCl)

• Acute Bronchiolitis:
  • Reduces hospital stay by 10–24 hours.
• Chronic Use:
  • Reserved for cystic fibrosis (improves mucociliary clearance).

4. Ipratropium (Atrovent)

• Acute Asthma Exacerbations:
  • Add to salbutamol in moderate-severe cases (e.g., O₂ saturation <92%).
  • Dose: 250 mcg nebulized q20min × 3 doses (AAP).
• No Role in Stable Asthma: Insufficient evidence for maintenance therapy.

5. Epinephrine (Adrenaline)

• Upper Airway Indications:
  • Croup: 5 mL of 1:1,000 solution nebulized (single dose).
  • Anaphylaxis: IM route preferred; nebulized epinephrine may be used adjunctively for severe upper airway obstruction (off-label).
• Avoid in Lower Airway Disease:
  • No proven benefit for asthma/bronchiolitis.
• Epinephrine (Adrenaline) (1mg/ml) Must be freshly prepared 
  • > 4 years 0.5 ml/kg (Max 5 ml)