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Administration of Aerosolized Medications – Adult/Pediatric – Inpatient/Ambulatory

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1
Administration of Aerosolized
Medications – Adult/Pediatric –
Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 4
METHODOLOGY ...................................................................................................................... 4
INTRODUCTION ....................................................................................................................... 4
RECOMMENDATIONS .............................................................................................................. 4
TABLE 1: NEBULIZED MEDICATIONS .................................................................................... 5
TABLE 2: METERED DOSE INHALERS .................................................................................10
UW HEALTH IMPLEMENTATION ............................................................................................13
REFERENCES .........................................................................................................................13
APPENDIX A – QUALITY OF EVIDENCE AND STRENGTH OF RECOMMENDATION
GRADING MATRIX
1
.................................................................................................................16
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2
CPG Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS – Manager, Drug Policy Program
Phone Number: 608-263-1328
Email Address: ptrapskin@uwhealth.org
CPG Contact for Content:
Name: Cindy Gaston, PharmD, BCPS – Pharmacy Department
Phone number: 608-265-8161
Email address: cgaston@uwheatlh.org
Guideline Update Author:
E. Shannon, PharmD, MS – Pharmacy Department
Coordinating Team Members:
C. Gaston, PharmD, BCPS – Pharmacy Department
Review Individuals/Bodies:
J. Halfpap, PharmD – Pharmacy Department
Committee Approvals/Dates:
Antimicrobial Use Subcommittee (10/13/2015)
Respiratory Care Committee (11/12/2015)
P&T Committee (Last Periodic Review: 12/17/2015)
Release Date: February 2016 | Next Review Date: December 2018
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3
Executive Summary
Guideline Overview
This guideline provides direction on the appropriate dosing, utilization and administration of
aerosolized respiratory medications across UW Health.

Key Practice Recommendations
Table 1: Nebulized Medications
Table 2: Metered Dose Inhalers

Companion Documents
Diagnosis and Management of Asthma – Adult/Pediatric – Clinical Practice Guideline
Chronic Obstructive Pulmonary Disease – Adult – Ambulatory/Primary Care/Inpatient – Clinical
Practice Guideline
UWHC Hazardous Drug List

Pertinent UWHC Policies & Procedures
UWHC Policy 2.25: Inhaler Medication Treatment
UWHC Policy 1.40: Cleaning & Changing of Patient Care Equipment
UWHC Policy 8.89: Preventing Non-Therapeutic Exposure to Hazardous Drugs

Patient Resources:
HFFY #5060: Cromolyn
HFFY #4668: Adrenergic Bronchodilators
HFFY #6657: Asthma Controller Medicine, Inhaled Corticosteroids
HFFY #6729: Asthma Controller Medicine, Inhaled Corticosteroids (Spanish)
HFFY #6844: Asthma Controller Medicine, Inhaled Corticosteroid & Long Acting Bronchodilator
HFFY #5370: Nebulized Amphotericin B
HFFY #6660: Asthma Rescue Medicine
HFFY #6662: Asthma Controller Medicine – Leukotriene Modifiers
HFFY #7020: Nebulized Cayston
HFFY #4714: Nebulized Tobramycin
HFFY #5851: Nebulized Colistin
HFFY #4932: Nebulized Dornase Alfa or Pulmozyme
HFFY #4311: Ribavirin Treatment of Respiratory Syncytial Virus (RSV)
HFFY #5527: Aerosolized Pentamidine
HFFY #6658: Pulmicort Flexhaler
HFFY #5831: Inhaled Lidocaine Nebulizer Treatment
HFFY #6355: Nebulized Hypertonic Saline









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4
Scope
Disease/Condition(s): This guideline directs the appropriate administration of respiratory
medications across UW Health throughout inpatient and ambulatory practice settings.

Clinical Specialty: This guideline is intended for all personnel authorized to administer
respiratory medications in all clinical areas of pediatric and adult practice.

Intended Users: Physicians, Pharmacists, Respiratory Therapists, Nurses

Objective(s): To provide guidelines for administration of UW Health formulary respiratory
medications.

Target Population: Adult and pediatric patients within UW Health requiring administration of
medications through the respiratory route.

Major Outcomes Considered: Effective and safe administration of aerosolized respiratory
medications without undue patient harm.

Guideline Metrics: Patient Safety Net reports will be monitored for errors or adverse events
associated with aerosolized respiratory medication administration.
Methodology
Methods Used to Collect/Select the Evidence:
Evidence was obtained from the clinical literature, manufacturer prescribing information and
tertiary care references.

Methods Used to Assess the Quality and Strength of the Evidence:
A modified Grading of Recommendations Assessment, Development and Evaluation (GRADE)
developed by the American Heart Association and American College of Cardiology has been
used to assess the Quality and Strength of the Evidence in this Clinical Practice Guideline.
1

(Appendix A).

Methods Used to Formulate the Recommendations:
Evidence available in the literature, manufacturer prescribing information, and tertiary care
references were utilized at the time of guideline creation to formulate recommendations.

Introduction
Medications administered via nebulization or inhalation provides an opportunity to administer
treatment directly to the lungs for asthma, chronic obstructive pulmonary disease (COPD) and
other respiratory diseases. Additionally, the lungs provide a large surface area for medication
absorption for the treatment of systemic diseases.
2
Administration of medication via nebulization
may be useful in cases where the oral or intravenous route is not an option.

The following tables provide general guidelines, monitoring parameters, equipment information,
and patient education pearls for the administration of select UWHC respiratory medications.

Recommendations
All recommendations have a Class I, Level A recommendation, unless otherwise noted.
1

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5
Table 1: Nebulized Medications
Medication
Nebulized
Pediatric Dose
Nebulized Adult
Dose
Diluent Indication Side Effects
May Be Mixed
With
Equipment Used
Acetylcysteine
3

(Acetadote
®
)
Infants: 1 to 2 mL
of 20% solution
every 6 to 8 hr

Children: Refer to
adult dosing

Consider
pretreatment with
bronchodilator
4 mL of the 20%
solution every 8 hr

Consider
pretreatment with
bronchodilator.
Unit Dose—no
further dilution
necessary
Mucolytic
(helps clear
secretions)
Bronchospasm,
sore throat,
nausea
None
Standard nebulizer
or IPV; instill via
ETT for intubated
patients.
Albuterol
3

1.25 to 2.5 mg
every 6 to 8 hr
2.5 mg/3 mL or 2.5
mg/0.5 mL
every 6 to 8 hr
Unit Dose—no
further dilution
necessary
Bronchodilator
Tachycardia,
anxiety, occasional
allergy to
preservative
Ipratropium; use
non-diluted
albuterol when
mixing with
ipratropium to
decrease volume
nebulized
Standard nebulizer
or IPV
Albuterol/Ipratropium
solution for nebulizer
3

(DuoNeb
®
)
Not established
Initial dose: 3 mL
every 6 hr
Maximum dose: 3
mL every 4 hr
Unit Dose—no
further dilution
necessary
Bronchodilator for
COPD
Tachycardia,
anxiety
Patients with soy
and/or peanut
allergies SHOULD
NOT use
Combivent
®

None
Standard nebulizer
or IPV
Amikacin
3

(Class IIb, Level B)
Pre-treat with
bronchodilator

250 to 500 mg
every 12 hr
4-7

Pre-treat with
bronchodilator

500 mg every 12
hr
8

Dilute with normal
saline to a volume
of 6 mL
Inhaled antibiotic
for lung infections
Shortness of
breath, nausea,
excessive
coughing, sore
throat, dysphonia
None Standard nebulizer
Amphotericin B
Pre-treat with
bronchodilator

5-10 mg every 8 to
12 hr
9-11

(Class IIb, Level C)
Pre-treat with
bronchodilator

5-10 mg three to
four times daily.
12-
14
(Class I, Level
A) Double this
dose if patient is
intubated
14
(Class
IIb, Level C)
Supplied by
pharmacy (10
mg/2mL).
Needs to be further
diluted in 3 mL
sterile water for
injection
Inhaled antifungal
for lung infections
Shortness of
breath, sore throat,
nausea
None
Standard
nebulizer. No other
medications can
be put in this
nebulizer
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6
Medication
Nebulized
Pediatric Dose
Nebulized Adult
Dose
Diluent Indication Side Effects
May Be Mixed
With
Equipment Used
Alteplase (t-PA)
15,16

12 mg then 5 mg
every 2 hr
Taper down based
on clinical
response
(Class IIa, Level C)
Not established
Reconstituted to 2
mg/mL with normal
saline
Plastic Bronchitis
with Fontan
Procedure
No side effects
reported in case
reports
None
Standard
nebulizer. No other
medications can
be put in this
nebulizer.
Aztreonam
3

(Cayston®)
Age <7 years: 75
mg three times
daily
17

(Class IIa, Level B)
Premedication with
bronchodilator
recommended
Age 7 yrs and
older: 75 mg three
times daily
Premedication with
bronchodilator
recommended
Use diluent
provided by
manufacturer;
0.17% sodium
chloride, 1 mL
ampule
Inhaled antibiotic
for Pseudomonas
aeruginosa
Rash, facial
swelling, throat
tightening
None Altera Nebulizer
Budesonide
3

(Pulmicort Respules®)
0.25 to 1 mg every
12 to 24 hr,
depending on
previous therapy
0.25 or 0.5 mg
every 12 to 24 hr
Unit Dose—no
further dilution
necessary
Inhaled
corticosteroid
Sore throat,
hoarseness
None Standard nebulizer
Colistimethate (Colistin
Base)
3,18

Pre-treat with
bronchodilator
75 to 150 mg
every 8 to 12 hr
Pre-treat with
bronchodilator
75 to 150 mg
every 8 to 12 hr
Comes diluted
from the
pharmacy. Further
dilute to total
volume of 3 to 4
mL with normal
saline.
Inhaled antibiotic
for lung infections
Shortness of
breath, nausea
None
Standard nebulizer
or IPV
Cromolyn (Intal)
3

Age >2 yr: 20 mg
every 6 hr
20 mg every 6 hr
(20 mg/2 mL)
Unit Dose—no
further dilution
necessary
Mast cell stabilizer
for asthma
Cough, sore throat,
wheezing
Albuterol; use non-
diluted
Standard nebulizer
or IPV
Dornase
3,19-21

(Pulmozyme®)
Dornase Alfa -
Pediatric/Adult -
Inpatient
2.5 mg every 12 to
24 hr
(Class I, Level B)
Age >5 yr: Use
Adult dose
2.5 mg every 12 to
24 hr
Unit Dose—no
further dilution
necessary
Thins secretions in
CF patients
Sore throat, lost
voice, shortness of
breath
None
Standard
nebulizer. No other
medications can
be put in this
nebulizer.
Epoprostenol Please refer to the UW Health Clinical Practice Guideline: Epoprostenol Inhaled – Adult/Pediatric/Neonatal - Inpatient
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Medication
Nebulized
Pediatric Dose
Nebulized Adult
Dose
Diluent Indication Side Effects
May Be Mixed
With
Equipment Used
Hypertonic saline
3,22-24

Pre-treat with
bronchodilator

4 mL of 7%
solution
every 12 hr
(Class I, Level B)
Pre-treat with
bronchodilator

4 mL of 7%
solution
every 12 hr
No further dilution
necessary
Assist with
secretion
clearance
Sore throat,
wheezing,
bronchospasm
None
Standard nebulizer
or IPV
Ipratropium
3

(Atrovent®)
Age 5-11 yr: 125
to 250 mcg every 8
hr

Age > 12 yr: 250 to
500 mcg every 6 to
8 hr
500 mcg every 4 to
8 hr

Unit Dose—no
further dilution
necessary
Bronchodilator
NOTE: Nebulized
ipratropium DOES
NOT contain soy
lecithin, thus it can
be safely
administered to
patients with soy
allergies.
Bad taste in
mouth, sore throat,
sinusitis
Albuterol
Standard nebulizer
or IPV
Levalbuterol
3


RESTRICTED TO
USE IN NEONATES
RESTRICTED TO
USE IN
NEONATES
(unless patient’s
own supply)

Age <4 yr:
0.31 to 1.25 mg
every 4 to 6 hr as
needed

Age 5 to 11 yr:
0.31 to 0.63 mg
every 4 to 6 hr
RESTRICTED TO
USE IN
NEONATES
(unless patient’s
own supply)


0.63 to 1.25 mg
every 4 to 6 hr as
needed

Unit Dose—no
further dilution
necessary
Bronchodilator
Tachycardia,
anxiety, occasional
allergy to
preservative
Ipratropium Standard nebulizer
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8
Medication
Nebulized
Pediatric Dose
Nebulized Adult
Dose
Diluent Indication Side Effects
May Be Mixed
With
Equipment Used
Lidocaine
Cough: 1-3
mg/kg/dose of
either 1% or 2% as
needed, as
directed.
Recommended
maximum dose:
100 mg 4 times
daily

Anesthetic: 4-8
mg/kg of 1% or
2%.
Recommended
maximum total
dose: 20 mg/kg per
procedure
25-27

(Class IIb, Level B)
Cough: 1-5 mL of
1%-4% as needed,
as directed.
Recommended
maximum dose:
160 mg 4 times
daily

Anesthetic: 3-5 mL
of 2% or 4%.
Recommended
maximum dose:
400 mg per
procedure
28-31

(Class IIb, Level C)


None—no further
dilution necessary
Anesthetic;
reduces bronchial
hyper-reactivity;
Chronic cough
Bad taste in
mouth, sore throat,
numb throat
None
Standard nebulizer

UW Health Health
Facts for You:
Nebulized
Lidocaine
Morphine
2 mg every 4 hr as
needed
32,33

(Class IIb, Level C)
5-30 mg every 4 hr
as needed
34-36

(Class IIb, Level B)
2 mL normal saline
Relieve shortness
of breath for end-
stage cardiac or
lung disease
Respiratory
depression,
confusion,
hypotension.
Caution when
giving to patients
with history of
asthma. Patient
may develop
respiratory
compromise due to
the blunting of the
sense of dyspnea.
None Standard nebulizer
Naloxone**
37-40
Not established
2 mg; may repeat
every 30 minutes
until satisfactory
response
Class IIa, Level C
3 mL normal saline
Opioid overdose.
Do NOT use in
patients with acute
respiratory distress
(RR<6)
Agitation,
diaphoresis,
vomiting
None
Standard nebulizer
with facemask
**Family members and employees on opioid medication should wear a mask during administration of nebulized naloxone and for 10 minutes after therapy is
completed to avoid second hand exposure.
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9
Medication
Nebulized
Pediatric Dose
Nebulized Adult
Dose
Diluent Indication Side Effects
May Be Mixed
With
Equipment Used
Pentamidine
3

Pre-treat with a
bronchodilator

300 mg every 30
days
Pre-treat with a
bronchodilator

300 mg every 30
days
Comes pre-diluted
with sterile water
from the pharmacy
(6 mL syringe).
DO not mix with
sodium chloride,
as precipitation will
occur.
Treatment or
prophylaxis of
Pneumocystis
jiroveci pneumonia
Bronchospasm,
sore throat,
nausea, allergy to
the antibiotic
None
Medicator® with
HEPA filter.
Medication must
be scavenged or
given in a negative
airflow room. All
people entering
room during and
30 minutes after
therapy should
wear a HEPA
mask.
Racemic epinephrine
3

0.5 mg every 15
minutes until
satisfactory
response
2.5 mg every 15
minutes until
satisfactory
response
2 mL normal saline
Reduce
supraglottic
swelling post-
extubation and in
croup
Tachycardia,
anxiety
None Standard nebulizer
Ribavirin
Please refer to the UW Health Policy & Procedure: Ribavirin Delivery via Small Particle Aerosol Generator (Spag-2) - Policy Number: 2.29
UW Health Ribavirin Health Facts for You: Ribavirin Treatment of RSV
Tobramycin
3

Pre-treat the
patient with a
bronchodilator

80 mg every12 hr
Pre-treat the
patient with a
bronchodilator

80 mg every 12 hr
Supplied as 80
mg/2 mL by
pharmacy. Diluent
is normal saline.
Inhaled antibiotic
for lung infections
Shortness of
breath, nausea
None
Standard nebulizer
or IPV

Tobramycin high-
dose
3

(TOBI®)
Pre-treat with a
bronchodilator

300 mg every 12
hr
Pre-treat with a
bronchodilator

300 mg every 12
hr
Unit Dose—no
further dilution
necessary
Inhaled antibiotic
for lung infections
Shortness of
breath, nausea
None
Standard
nebulizer. No other
medications can
be put in this
nebulizer.
Vancomycin
8,41

Pre-treat with a
bronchodilator

250 mg every 12
hr
Pre-treat with a
bronchodilator

250 mg every 12
hr
5 mL normal saline
Upper & lower
respiratory
colonization of
MRSA
Bronchospasm None
Standard
nebulizer. No other
medications can
be put in this
nebulizer.

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10
Table 2: Metered dose inhalers
Medication
Inhaled
Pediatric Dose
Inhaled
Adult Dose
Indication Side Effects Equipment Used Special Instructions
Albuterol HFA
3

(Ventolin HFA
®
,
ProAir
®
HFA is
restricted to pediatric
ventilated patients
only)
2 inhalations every
4 to 6 hr
(90 mcg/inhalation)
2 inhalations every
4 to 6 hr
(90 mcg/inhalation)
Bronchodilator
Tachycardia,
anxiety
Aerochamber
®

Teach patient how to prime the MDI
and how to determine the number of
puffs remaining.
Albuterol/Ipratropium
3

(Combivent
®
)
Not established
2 inhalations four
times daily
Bronchodilator for
COPD
Tachycardia,
anxiety
Patients with soy
and/or peanut
allergies SHOULD
NOT use
Combivent
®

Aerochamber
®

Teach patient how to determine the
number of puffs remaining.
Budesonide
3,42

(Pulmicort Flexhaler
®
)
Age > 6 yr:
180 to 360 mcg
twice daily

180 to 360 mcg
twice daily (max
720 mcg twice
daily)
Inhaled
corticosteroid to
decrease
inflammation
Sore throat, thrush,
headache
Dry powder
Turbuhaler
®

Make sure patient rinses mouth after
use to prevent thrush. Instruct patient
not to store medication in warm and/or
moist location. Medication block will
be damaged if inhaler is dropped.
Budesonide/Formoterol
Fumarate
3

(Symbicort)
NON-FORMULARY
Age 5-11 yr:
2 inhalations twice
daily (80/4.5)
Age >12:
Use adult dose
2 inhalations twice
daily (80/4.5 OR
160/4.5)
Long-acting
bronchodilator and
inhaled steroid
Tachycardia,
anxiety, sore throat,
thrush
HFA with
Aerochamber
®

Teach patient how to prime the MDI
and determine how many puffs remain.

Make sure patient rinses mouth after
use to prevent thrush.
Fluticasone Diskus
3

(Flovent Diskus
®
)
Age 4 to 11 yr:
50 to 100 mcg
twice daily
Age >12 yr:
Use adult dose
100 to 250 mcg
twice daily
Inhaled
corticosteroid to
decrease
inflammation
Sore throat, thrush Diskus
®
inhaler
Make sure patient rinses mouth after
use to prevent thrush. Instruct patient
not to store medication in warm and/or
moist location.
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11
Medication
Inhaled
Pediatric Dose
Inhaled
Adult Dose
Indication Side Effects Equipment Used Special Instructions
Fluticasone HFA
3

(Flovent HFA
®
)
Age 4-11 yr:
88 mcg
every 12 hr
Age > 12 yr:
Use adult dose
88 to 440 mcg
every 12 hr
Inhaled
corticosteroid to
decrease
inflammation
Sore throat, thrush Aerochamber
®

Make sure patient rinses mouth after
use to prevent thrush. Teach patient
how to prime the MDI and how to
determine the number of puffs
remaining.
Fluticasone/Salmeterol
Diskus
3

(Advair Diskus
®
)
Ages 4-11 yr: 1
inhalation every 12
hrs (100/50). This
is maximum dose

Ages > 12 yr:
Refer to adult
dosing
Asthma:
1 inhalation every
12 hr
(100/50, 250/50 or
500/50 mcg)

COPD:
1 inhalation every
12 hr (250/50 mcg,
500/50 mcg)
Long-acting
bronchodilator and
inhaled steroid
Tachycardia,
anxiety, sore throat,
thrush
Diskus
®
inhaler
Make sure patient rinses mouth after
use to prevent thrush. Instruct patient
not to store medication in warm and/or
moist location.
Fluticasone/Salmeterol
HFA
3

(Advair HFA
®
)
Age >12 yr: Use
adult dose
2 inhalations every
12 hr
(45/21, 115/21 or
230/21 mcg)
Long-acting
bronchodilator and
inhaled steroid
Tachycardia,
anxiety, sore throat,
thrush
Aerochamber
®

Teach patient how to prime the MDI
and how to determine the number of
puffs remaining
Ipratropium HFA
3,42,43

(Atrovent HFA
®
)
Acute moderate to
severe asthma
exacerbations:
Age <5 yr: 2
inhalations every
20 mins for one
hour
Age 6-12 yr: 4 to 8
inhalations every
20 mins as needed
for up to 3 hr
Age >13 yr: Use
adult dose
COPD:
2 inhalations
four times daily

Acute asthma
exacerbation:
8 inhalations every
20 mins as needed
for up to 3 hr
Bronchodilator
Bad taste in mouth,
sore throat.
Patients with soy
and/or peanut
allergies MAY use.
Aerochamber
®

Teach patient how to prime the MDI
and how to determine the number of
puffs remaining
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12
Medication
Inhaled
Pediatric Dose
Inhaled
Adult Dose
Indication Side Effects Equipment Used Special Instructions
Salmeterol Diskus
3

(Serevent®)
Age >4 yr: Use
adult dose

1 inhalation (50
mcg) every 12 hr

Long-acting
bronchodilator
Tachycardia,
anxiety
Diskus® inhaler
Instruct patient not to store medication
in warm and/or moist location.
Tiotropium
3

(Spiriva® Handihaler)
Dose not
established
Inhale 1 (18 mcg)
capsule daily
Bronchodilator for
COPD
Pharyngitis, dry
mouth, urinary
retention (rare)
Dry powder
Handihaler®
Place one capsule in the inhaler and
puncture before use
Tiotropium
3

(Spiriva® Respimat)
NON FORMULARY
Ages <12 yr: Dose
not established

Ages ≥ 12 yr: Use
adult asthma dose

Asthma:
2 inhalations (5
mcg) once daily

COPD: 2
inhalations (5 mcg)
once daily
(maximum of 2
inhalations per 24
hrs)
Bronchodilator for
COPD and
bronchodilator for
maintenance
treatment of
asthma
Pharyngitis, dry
mouth, urinary
retention (rare)
Aerochamber
®

Teach patient how to determine the
number of puffs remaining

Abbreviations: CF=Cystic Fibrosis; COPD=Chronic Obstructive Pulmonary Disease; ETT=Endotracheal Tube; HFA=Hydrofluoroalkane (propellant); IPV=Intrapulmonary Percussive
Ventilation; MDI=Metered-Dose Inhaler; NSS=Normal Saline Solution
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13
UW Health Implementation
Potential Benefits:
This clinical practice guideline provides a standardized approach to the administration of
respiratory medications to adult and pediatric patients being treated in the inpatient and
ambulatory settings. A decreased risk of adverse events secondary to inappropriate
administration of respiratory medications is possible through implementation of this guideline.

Potential Harms:
Medications carry potential risk for undesired side effects and/or adverse events due to the
pharmacologic action; however, risks of medications included in this guideline are rarely
serious.

Qualifying Statements
Recommendations are based on evidence available at the time of guideline creation.
Administration of aerosolized respiratory medications should consider patient specific
characteristics and goal of therapy.

Implementation Plan
This guideline will be available on UConnect and cross referenced in guidelines and protocols.
New medication records will be created for new medication additions
Respiratory Therapist will be educated on updates to the guideline.

Implementation Tools
HealthLink medication records will include a link to this guideline to support accessibility of this
reference.
LexiComp entries for medications described within this guideline will be updated with
appropriate links to this reference.

Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach for most
patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all
patients. It is understood that some patients will not fit the clinical condition contemplated by a
guideline and that a guideline will rarely establish the only appropriate approach to a problem.
References
1. Jacobs AK, Kushner FG, Ettinger SM, et al. ACCF/AHA clinical practice guideline methodology summit report: a
report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines. J Am Coll Cardiol. 2013;61(2):213-265.
2. Labiris NR, Dolovich MB. Pulmonary drug delivery. Part I: physiological factors affecting therapeutic
effectiveness of aerosolized medications. Br J Clin Pharmacol. 2003;56(6):588-599.
3. Lexi-Drugs Online™ Hudson, OH: Lexi-Comp, Inc; 2014; Accessed Dec 2014.
4. Lebecque P, Leal T, Zylberberg K, Reychler G, Bossuyt X, Godding V. Towards zero prevalence of chronic
Pseudomonas aeruginosa infection in children with cystic fibrosis. J Cyst Fibros. 2006;5(4):237-244.
5. Okusanya OO, Bhavnani SM, Hammel J, et al. Pharmacokinetic and pharmacodynamic evaluation of liposomal
amikacin for inhalation in cystic fibrosis patients with chronic pseudomonal infection. Antimicrob Agents
Chemother. 2009;53(9):3847-3854.
6. Clancy JP, Dupont L, Konstan MW, et al. Phase II studies of nebulised Arikace in CF patients with Pseudomonas
aeruginosa infection. Thorax. 2013;68(9):818-825.
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14
7. Schaad UB, Wedgwood-Krucko J, Suter S, Kraemer R. Efficacy of inhaled amikacin as adjunct to intravenous
combination therapy (ceftazidime and amikacin) in cystic fibrosis. J Pediatr. 1987;111(4):599-605.
8. Le J, Ashley ED, Neuhauser MM, et al. Consensus summary of aerosolized antimicrobial agents: application of
guideline criteria. Insights from the Society of Infectious Diseases Pharmacists. Pharmacotherapy.
2010;30(6):562-584.
9. Moss RB. Allergic bronchopulmonary aspergillosis and Aspergillus infection in cystic fibrosis. Curr Opin Pulm
Med. 2010;16(6):598-603.
10. Hayes D, Jr., Murphy BS, Lynch JE, Feola DJ. Aerosolized amphotericin for the treatment of allergic
bronchopulmonary aspergillosis. Pediatr Pulmonol. 2010;45(11):1145-1148.
11. Laoudi Y, Paolini JB, Grimfed A, Just J. Nebulised corticosteroid and amphotericin B: an alternative treatment for
ABPA? Eur Respir J. 2008;31(4):908-909.
12. Amphotericin B (Fungizone) [prescribing information]. Bristol-Myers Squibb; Montreal, Canada 2009.
13. Drew RH, Dodds Ashley E, Benjamin DK, Jr., Duane Davis R, Palmer SM, Perfect JR. Comparative safety of
amphotericin B lipid complex and amphotericin B deoxycholate as aerosolized antifungal prophylaxis in lung-
transplant recipients. Transplantation. 2004;77(2):232-237.
14. Quon BS, Goss CH, Ramsey BW. Inhaled antibiotics for lower airway infections. Ann Am Thorac Soc.
2014;11(3):425-434.
15. Lubcke NL, Nussbaum VM, Schroth M. Use of aerosolized tissue plasminogen activator in the treatment of
plastic bronchitis. Ann Pharmacother. 2013;47(3):e13.
16. Do TB, Chu JM, Berdjis F, Anas NG. Fontan patient with plastic bronchitis treated successfully using aerosolized
tissue plasminogen activator: a case report and review of the literature. Pediatr Cardiol. 2009;30(3):352-355.
17. Tiddens HA, De Boeck K, Clancy JP, et al. Open label study of inhaled aztreonam for Pseudomonas eradication
in children with cystic fibrosis: The ALPINE study. J Cyst Fibros. 2015;14(1):111-119.
18. Michalopoulos A, Fotakis D, Virtzili S, et al. Aerosolized colistin as adjunctive treatment of ventilator-associated
pneumonia due to multidrug-resistant Gram-negative bacteria: a prospective study. Respir Med.
2008;102(3):407-412.
19. Berge MT, Wiel E, Tiddens HA, Merkus PJ, Hop WC, de Jongste JC. DNase in stable cystic fibrosis infants: a
pilot study. J Cyst Fibros. 2003;2(4):183-188.
20. Quan JM, Tiddens HA, Sy JP, et al. A two-year randomized, placebo-controlled trial of dornase alfa in young
patients with cystic fibrosis with mild lung function abnormalities. J Pediatr. 2001;139(6):813-820.
21. Frederiksen B, Pressler T, Hansen A, Koch C, Hoiby N. Effect of aerosolized rhDNase (Pulmozyme) on
pulmonary colonization in patients with cystic fibrosis. Acta Paediatr. 2006;95(9):1070-1074.
22. Jacobs JD, Foster M, Wan J, Pershad J. 7% Hypertonic saline in acute bronchiolitis: a randomized controlled
trial. Pediatrics. 2014;133(1):e8-13.
23. Rosenfeld M, Ratjen F, Brumback L, et al. Inhaled hypertonic saline in infants and children younger than 6 years
with cystic fibrosis: the ISIS randomized controlled trial. JAMA. 2012;307(21):2269-2277.
24. Elkins MR, Robinson M, Rose BR, et al. A controlled trial of long-term inhaled hypertonic saline in patients with
cystic fibrosis. N Engl J Med. 2006;354(3):229-240.
25. Moustafa MA. Nebulized lidocaine alone or combined with fentanyl as a premedication to general anesthesia in
spontaneously breathing pediatric patients undergoing rigid bronchoscopy. Paediatr Anaesth. 2013;23(5):429-
434.
26. Babl FE, Goldfinch C, Mandrawa C, Crellin D, O'Sullivan R, Donath S. Does nebulized lidocaine reduce the pain
and distress of nasogastric tube insertion in young children? A randomized, double-blind, placebo-controlled trial.
Pediatrics. 2009;123(6):1548-1555.
27. Gjonaj ST, Lowenthal DB, Dozor AJ. Nebulized lidocaine administered to infants and children undergoing flexible
bronchoscopy. Chest. 1997;112(6):1665-1669.
28. Sharma GK, Verma SP. Is Nebulized Lidocaine Adequate Topical Anesthesia for Diagnostic Transnasal
Tracheoscopy? Ann Otol Rhinol Laryngol. 2015;124(7):545-549.
29. Trochtenberg S. Nebulized lidocaine in the treatment of refractory cough. Chest. 1994;105(5):1592-1593.
30. Udezue E. Lidocaine inhalation for cough suppression. Am J Emerg Med. 2001;19(3):206-207.
31. Lim KG, Rank MA, Hahn PY, Keogh KA, Morgenthaler TI, Olson EJ. Long-term safety of nebulized lidocaine for
adults with difficult-to-control chronic cough: a case series. Chest. 2013;143(4):1060-1065.
32. Cohen SP, Dawson TC. Nebulized morphine as a treatment for dyspnea in a child with cystic fibrosis. Pediatrics.
2002;110(3):e38.
33. Janahi IA, Maciejewski SR, Teran JM, Oermann CM. Inhaled morphine to relieve dyspnea in advanced cystic
fibrosis lung disease. Pediatr Pulmonol. 2000;30(3):257-259.
34. Westphal CG, Campbell ML. Nebulized morphine for terminal dyspnea. Am J Nurs. 2002;Suppl:11-15.
35. Zeppetella G. Nebulized morphine in the palliation of dyspnoea. Palliat Med. 1997;11(4):267-275.
36. Polosa R, Simidchiev A, Walters EH. Nebulised morphine for severe interstitial lung disease. Cochrane
Database Syst Rev. 2002(3):CD002872.
37. Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB. Can nebulized naloxone be used safely and effectively
by emergency medical services for suspected opioid overdose? Prehosp Emerg Care. 2012;16(2):289-292.
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38. Astermark J, Santagostino E, Keith Hoots W. Clinical issues in inhibitors. Haemophilia. 2010;16 Suppl 5:54-60.
39. Mycyk MB, Szyszko AL, Aks SE. Nebulized naloxone gently and effectively reverses methadone intoxication. J
Emerg Med. 2003;24(2):185-187.
40. Baumann BM, Patterson RA, Parone DA, et al. Use and efficacy of nebulized naloxone in patients with
suspected opioid intoxication. Am J Emerg Med. 2013;31(3):585-588.
41. Hayes D, Jr., Murphy BS, Mullett TW, Feola DJ. Aerosolized vancomycin for the treatment of MRSA after lung
transplantation. Respirology. 2010;15(1):184-186.
42. Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic
review and cumulative meta-analysis. BMJ. 2012;344:e3054.
43. Hylek EM, Evans-Molina C, Shea C, Henault LE, Regan S. Major hemorrhage and tolerability of warfarin in the
first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007;115(21):2689-2696.
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16
Appendix A – Quality of Evidence and Strength of Recommendation Grading Matrix
1


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