Nebulized Budesonide Guideline Summary

Introduction to Nebulized Budesonide

Nebulized budesonide can be used as an alternative to oral prednisolone in non-acidotic COPD exacerbations, with possible indications including stridor, lymphangitis carcinomatosa, radiation pneumonitis, or cough after insertion of an endobronchial stent, at a standard dosage of 500 μg 12 hourly (twice daily) 1
The American Thoracic Society recommends nebulized budesonide for the management of respiratory conditions, including asthma and COPD exacerbations, with a standard dosage of 500 μg twice daily for most adult indications and 1-2 mg twice daily for acute exacerbations, although the evidence supporting this practice is limited (Grade C recommendation) 1

Only jet nebulizers should be used for nebulized budesonide, as ultrasonic nebulizers are ineffective for suspensions, and pretreatment with a β-agonist by handheld inhaler or nebulizer is recommended to prevent bronchospasm 1
The optimal dosing for exacerbations is 2 mg every 6 hours (total 8 mg/day) or 4 mg twice daily, with the 4 mg twice daily regimen showing better improvement in FEV1%, FEF50%, FEF25-75%, and CAT scores, although the evidence is not explicitly stated to be from a specific guideline society 1
The European Respiratory Society recommends that patients should not stop therapy without physician guidance as symptoms may recur, and regular clinical follow-up to assess symptom control is necessary 2

Local effects of nebulized budesonide include cough, dysphonia, and oral candidiasis, while systemic effects are less common with nebulized vs. oral corticosteroids, but may include potential for adrenal suppression at high doses, growth suppression concerns in children, and bone density effects with long-term use 2
Regular growth monitoring in children and consideration of regular eye examinations with long-term use due to potential risk of cataracts or glaucoma are recommended, although the strength of the evidence for these recommendations is not provided 2

Nebulized budesonide may be used before physiotherapy to mobilize secretions in cystic fibrosis, although objective evidence of added benefit is lacking, and it is not intended for relief of acute asthma symptoms, with a rescue inhaler recommended to be available 1
The guideline society recommends that nebulized budesonide is an effective alternative to inhalers for patients unwilling or unable to use inhalers properly, although the evidence for this is not explicitly stated to be from a specific guideline society, and no evidence suggests that nebulized corticosteroids are superior to handheld inhalers or oral steroids in palliative settings 1