Royal London Hospital Author: Rachel O’Connor, June 2019

Contents

Part 1: Nebuliser Therapy

1. Jet Nebulisers
   • Respironics Sidestream with angled mouthpiece
   • Pari LC Family
     • Pari LC Plus
     • Pari LC Sprint
     • Pari LC Sprint Junior
     • Pari LC Sprint Star
2. Compressors (for use with jet nebulisers)
3. Vibrating Mesh Nebulisers
   • Pari eFlow Rapid
   • iNeb
   • Aerogen
4. Devilbiss Ultrasonic Nebuliser

Part 2: Drugs for Nebulisation

1. Bronchodilators
   • Salbutamol
   • Ipratropium bromide
2. Mucoactives
   • Hypertonic saline (3-7%)
   • DNase
   • N-AC
3. Antibiotics (various)
4. Which nebuliser for which drug?

Part 1: Nebuliser Therapy

Learning Level: Foundation / Intermediate

Introduction

Drug delivery via inhalation is the mainstay of treatment for many respiratory diseases. The lungs provide an efficient route for the administration of several classes of drugs, as they allow receptors in the airways to be targeted by therapeutic agents. The aim of nebuliser therapy is to safely and effectively deliver a therapeutic dose of the required drug to the patient as an aerosol in the form of respiratory particles.

The individual’s and/or carer’s ability to use the nebuliser should be assessed before prescribing and appropriate support and maintenance of equipment should be available. Nebuliser treatment should be continued where there is benefit for the patient — improvement in symptoms, daily living activities, exercise capacity or lung function.

Factors Determining Aerosol Delivery

1. Jet Nebulisers

Learning Level: Foundation

1a. Respironics Sidestream with Angled Mouthpiece

This is the basic jet nebuliser used for bronchodilators and some mucolytics and is available on the ward. All chronic respiratory patients should use a mouthpiece once they are old enough to do so. It is for use with oxygen or air via the wall at 6-8 LPM or with a compressor. They are available on most wards and always on 7E respiratory.

Note: Original document contains images of the Respironics Sidestream device at this point.

Medications

• Bronchodilators: Salbutamol & ipratropium bromide / Atrovent(R)
• Mucoactives: Hypertonic saline, N-Acetylcysteine (NAC)

Not to be used for

• DNase / Pulmozyme(R)
• Any nebulised antibiotics
• Liposomal Amphotericin B / AmBisome(R)

Can be combined with

• Acapella
• Incentive Spirometer using a t-piece

Note: Original document contains an additional image here, likely showing the device combined with accessories.

The Cirrus 2 is also stocked on the wards and can be used interchangeably.

1b. Pari LC Family

Learning Level: Foundation / Intermediate

These jet nebulisers have a breath enhanced valved system which again utilizes inspiratory flow to increase nebulisation rate. However, less medication is lost during expiration as the valve closes. These nebulisers have a greater predicted lung delivery but may have longer treatment times as there is less wastage during expiration.

Pari LC Plus

The Pari LC Plus is one of the most commonly used nebuliser pots for home use. It has been used in a variety of drug trials and is licenced for use in most antibiotics. It can be run through oxygen or air via the wall at 5 LPM or with a compressor.

It is available from the store room in 7E. Please note two different types — there is also a cost difference. Only use filter for nebulised antibiotics.

Note: Original document contains images of the Pari LC Plus device (2 images).

Medications

• Bronchodilators: Salbutamol & ipratropium bromide / Atrovent(R)
• Mucoactives: Hypertonic saline, N-Acetylcysteine (NAC), DNase / Pulmozyme(R)
• Antibiotics: Most antibiotics. Use with a filter set
• Antifungals: Liposomal Amphotericin B / AmBisome(R)

Not to be used for

• Following branded antibiotics: Cayston(R), Quinsair(R), Vantobra(R), Promixin(R)

Can be combined with

• PariPEP
• Acapella

Troubleshooting

If there appears to be a low resistance on the PEP when combining, there may be a leak from the one-way valve in the nebuliser. Try on resistance 1.5 — if not significant resistance, problem is likely nebuliser. Change to Pari LC Sprint.

You will hear when the patient has triggered a breath, which will increase the output — if you are not hearing this then the patient may be breathing through their nose or have an ineffective trigger.

Respirable Drug Dose

Note: Original document contains an image/chart showing respirable drug dose data.

Assembly

Note: Original document contains images showing assembly instructions for the Pari LC Plus.

Pari LC Sprint

Learning Level: Foundation / Intermediate

The Pari LC Sprint can be used in lieu of the Pari LC Plus. It has a faster nebulisation time, but a fractionally smaller respirable dose (see above). It can be run through oxygen or air via the wall at 5 LPM or with a compressor. The LC Sprint has several models: Sprint, Sprint Junior and Sprint Star, each with a different colour baffle insert.

It is available from the store cupboard in clinic 4 — the CNSs keep the key in their office. Please ensure it has the correct baffle colour.

Note: Original document contains images of the Pari LC Sprint device and its variants.

Baffle Variants

Medications

• Bronchodilators: Salbutamol & ipratropium bromide / Atrovent(R)
• Mucoactives: Hypertonic saline, N-Acetylcysteine (NAC), DNase / Pulmozyme(R)
• Antibiotics: Most antibiotics. Use with a filter set
• Antifungals: Liposomal Amphotericin B / AmBisome(R)

Not to be used for

• Following branded antibiotics: Cayston(R), Quinsair(R), Vantobra(R), Promixin(R)

Can be combined with

• PariPEP
• Acapella

Combining with PEP

The Pari LC Sprint is our nebuliser pot of choice if combining HTS with PEP while using a jet nebuliser.

Note: Original document contains an image showing the Sprint combined with PEP.

2. Compressors (for use with Jet Nebulisers)

Learning Level: Foundation

Jet nebulisers require a compressed gas source to drive them to create the aerosol. A jet of compressed air is forced through a small hole under pressure and expands rapidly. This causes negative pressure and suction. Fluid is pulled up through a secondary jet and atomised. Liquid droplets hit, or pass around a baffle and are either inhaled or impact on the internal wall of the chamber. Jet nebulisers are continuous and as such more than half of the drug is wasted during exhalation. The compressors below are those used at RLH for the jet nebulisers listed above.

Note: Original document contains images of compressor units used at RLH (at least 2 images).

For inpatients, the air outlet, or oxygen outlet if required can be used in lieu of a compressor. The patient will need a compressor if they are going home on the drug.

Note: Original document contains an additional image of the wall air/oxygen outlet setup.

Key point: Compressors need servicing once a year — this is usually arranged by the relevant CNS.

3. Vibrating Mesh Nebulisers

Learning Level: Intermediate / Advanced

3a. Pari eFlow Rapid Nebuliser System

The Pari eFlow(R) Rapid uses touch spray vibrating mesh technology and reduces inhalation time by 50% compared to the Pari LC Plus(R).

It is available from the store cupboard in clinic 4 — the CNSs keep the key in their office.

Note: Original document contains images of the Pari eFlow Rapid device (at least 2 images).

Medications

• Bronchodilators: Salbutamol & ipratropium bromide / Atrovent(R)
• Mucoactives: Hypertonic saline, N-Acetylcysteine (NAC), DNase / Pulmozyme(R)
• Antibiotics: Most antibiotics. Use with a filter set

Can be combined with

• PariPEP
• Acapella

Not to be used for

• Promixin(R) (colistin) unless dose altered
• Liposomal Amphotericin B / AmBisome(R)

Branded Drug-Specific Handsets

IMPORTANT: There are three handsets that must only be used for the drugs they have been created for:

Can be combined with

• PariPEP
• Aerobika

Pausing During Inhalation

If it is necessary to interrupt the inhalation session briefly, use the Pause function:

• Press the ON/OFF button for approx. 1 second. Pause mode is activated if the LED flashes green.
• Press the ON/OFF button for approx. 1 second again to resume the inhalation.

Note: Original document contains an image showing the eFlow control/display.

Key point: Note that about 1 ml of medication cannot be nebulised and remains unused in the medication reservoir; this residue must be discarded. This is necessary to ensure a safe quantity of medication is delivered and does not constitute a malfunction.

Note: Original document contains an image related to residual medication.

3b. Phillips iNeb (I-neb AAD System)

Learning Level: Advanced

The I-neb is the third generation AAD (Adaptive Aerosol Delivery) system. It is a small, battery powered, lightweight and virtually silent drug delivery device designed to significantly reduce the inconvenience of conventional nebulizer/compressor therapy while delivering a precise, reproducible dose of drug. The aerosol is created through VMT (vibrating mesh technology), and the dosage of drug is controlled through an AAD Disc and specific metering chambers. The metering chambers can deliver a pre-set volume ranging from 0.25 to 1.4 mL with a residual of about 0.1 mL.

Note: Original document contains images of the iNeb device (2 images).

Medications (Chamber-Specific)

Not to be used for

• Anything else!

Can be combined with

• Nil

3c. Aerogen Solo

Learning Level: Advanced

The Aerogen Solo is a new generation vibrating mesh nebuliser used predominantly in PCCU.

For further information please refer to the user guide in:

Q:\Children’s Therapies\Physios\Respiratory\6. Nebulisers\Aerogen Solo System

Note: Original document contains images of the Aerogen Solo system (2 images).

4. Devilbiss Ultrasonic Nebuliser

Learning Level: Intermediate

Only used for sodium chloride 0.9%-7% for either an induced sputum or therapeutically. See guideline for more information. This can be found at:

Q:\Children’s Therapies\Physios\Guidelines, Policies & SOPs\Respiratory\DeVilbiss Ultrasonic nebuliser

Part 2: Drugs for Nebulisation

Learning Level: Foundation / Intermediate

Drug Timing and Indications Table

Which Nebuliser for Which Drug?

IMPORTANT: This is brand specific — not all formulations of each drug can be used in each nebuliser.

Nebulised Antibiotics

Mucoactive Drugs

(Taken from Brompton guidelines for the care of children with cystic fibrosis)

Device Summary Comparison

Embedded Images in Original Document

The original Word document contains 22 embedded images, including:

• Device photographs (Respironics Sidestream, Pari LC Plus, Pari LC Sprint variants, eFlow Rapid, iNeb, Aerogen Solo, compressors)
• Assembly diagrams (Pari LC Plus assembly)
• Respirable drug dose charts
• Combination setup images (nebuliser + PEP)
• Baffle colour identification images for LC Sprint variants
• Compressor images
• Wall outlet setup images

References

1. Guidelines for Use of Nebuliser Systems in the Home Environment 2016, Irish Thoracic Society.
   • Updated (2026): This document was actually published in January 2017. Available at: https://irishthoracicsociety.com/wp-content/uploads/2017/05/Nebuliser-Guidelines.pdf. It remains the relevant Irish Thoracic Society reference for home nebuliser systems.
2. Clinical guidelines for the care of children with cystic fibrosis 2017, Royal Brompton Hospital.
   • Updated (2026): The 2017 edition has been superseded by the 2020 and then the 2023 (8th) edition, which is current through 2026. Current version: Royal Brompton & Harefield NHS Foundation Trust. Clinical Guidelines: Care of Children with Cystic Fibrosis, 8th edition, 2023. https://www.rbht.nhs.uk/childrencf. The nebuliser drug compatibility table in this guide should be checked against the 2023 edition.
3. Daniels T et al. 2015 Nebuliser systems for drug delivery in cystic fibrosis. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD007639. DOI: 10.1002/14651858.CD007639.pub2.
   • Updated (2026): The original Daniels et al. version (pub2) was published in April 2013 (the “2015” in the author line above is a citation error). The Cochrane review has since been updated in 2023 by Stanford G et al. (pub3). Updated DOI: 10.1002/14651858.CD007639.pub3. The 2023 update (20 studies, 1,936 participants) notes that newer nebuliser technologies (AAD, vibrating mesh) deliver medication faster and may deposit more drug in the lung.
4. Nebuliser therapy in cystic fibrosis. CF Trust Factsheet — July 2013.
   • Updated (2026): The 2013 factsheet has been superseded; the closest current CF Trust resource is the Inhaled therapy for people with cystic fibrosis factsheet (updated 2016): https://www.cysticfibrosis.org.uk/sites/default/files/2020-11/Factsheet%20%20Inhaled%20Therapies%202016.pdf. See also the CF Trust’s current online resources on nebuliser therapy.
5. Joint Formulary Committee (2017) BNF 74: September 2017. London: Pharmaceutical Press.
   • Updated (2026): BNF 74 (September 2017) is heavily outdated. For paediatric dosing, the current edition is BNFc 2025-2026 (Pharmaceutical Press, ISBN: 978-0857114884). The British National Formulary for Children (BNFc) is more appropriate than the adult BNF for this paediatric-focused guide. Online: https://bnfc.nice.org.uk/.

Source: RLH Nebuliser document 2019 - Copy.docx — Rachel O’Connor, June 2019, Royal London Hospital Paediatric Respiratory Physiotherapy Team