Respiratory Therapy in Pneumonia Management

Indications and Contraindications

Nebulizers are recommended over handheld inhalers in specific situations, such as when large drug doses are needed, controlled coordinated breathing is difficult, chronic lung disease is present, or in babies when inhalers with spacer and mask are not working, according to the British Thoracic Society guidelines 1
Nebulizers should only be used on a doctor's recommendation and are not first-line therapy for most cases of pneumonia, as stated by the British Thoracic Society guidelines 1
The British Thoracic Society recommends the use of nebulizers for patients with underlying respiratory conditions or bronchospasm, such as those requiring bronchodilators (β-agonists, anticholinergics) or antibiotics in specific situations like cystic fibrosis or certain resistant infections 1

Sterile fluid should be used for nebulization, dispensed aseptically, and single-dose medication vials are preferred whenever possible, as recommended by the Centers for Disease Control and Prevention (CDC) and the British Thoracic Society guidelines 1, 2
Water should never be used for nebulization as it may cause bronchoconstriction, according to the British Thoracic Society guidelines 1
0.9% Sodium chloride may be used to assist with physiotherapy and airway clearance, as recommended by the British Thoracic Society guidelines 1

Small-volume nebulizers should be cleaned, disinfected, rinsed with sterile water, and dried between treatments, as recommended by the CDC and the British Thoracic Society guidelines 1, 2
Disposable parts should be replaced every three months, or annually if long-lasting type, and the compressor should be serviced annually, according to the British Thoracic Society guidelines 1
The nebulizer should be cleaned after each use with warm water and mild detergent, and rinsed thoroughly and allowed to dry completely, as recommended by the British Thoracic Society guidelines 1

A gas flow rate of 6-8 L/min should be used to nebulize particles to 2-5 μm diameter for optimal deposition into small airways, as recommended by the British Thoracic Society guidelines 1
For most medications, 10 minutes of nebulization should be sufficient, according to the British Thoracic Society guidelines 1
A standard flow rate compressor (6 L/min) with a breath-enhanced open vent nebulizer should be used for nebulization, and mouthpieces rather than face masks (except for infants or young children) should be used, as recommended by the British Thoracic Society guidelines 1

Patients with pneumonia who are mechanically ventilated require special considerations, and vibrating-mesh nebulizers are preferred over jet or ultrasonic nebulizers, although this is not supported by a valid citation
Equipment failure may occur, and patients should revert to handheld inhalers until the equipment can be repaired, as recommended by the British Thoracic Society guidelines 1
Patients should be monitored for worsening symptoms, persistent fever beyond 3-4 days, shortness of breath, or symptoms lasting longer than 10-14 days, and nebulizers should only be used on a doctor's recommendation, with patients aware of the potential risks and benefits of nebulization therapy, including the use of normal saline as a safer alternative 1
Nebulized 0.9% saline (normal saline) is a safer and more effective alternative for symptom relief, and should be used instead of water nebulization, which may cause bronchoconstriction and is potentially harmful, as recommended by the Thorax guidelines and the British Thoracic Society guidelines 1, 3
0.9% Saline (Normal Saline) Nebulization provides moisture to respiratory epithelia, improves mucociliary clearance, is safe for all age groups, has no risk of medication side effects, and can be administered 3-4 times daily as needed, according to the British Thoracic Society guidelines 1