Review in progress
Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.
Acute management- Asthma
- When managing an acute exacerbation of asthma in the community with nebulised bronchodilators the patient's response must be closely monitored.
- It is not appropriate to treat patients with significant exacerbations of asthma in the home environment, as patients require close supervision due to the speed with which the condition may deteriorate.
- Initial treatment with nebulised bronchodilator in the surgery is appropriate, however, patients showing symptoms of anything other than mild to moderate exacerbation which fully responds to bronchodilation must be referred to the Accident and Emergency department where they can undergo a more comprehensive assessment of their condition. (add link to acute exacerbation Asthma)
- Continued treatment with nebulised therapy in the patient's home is not appropriate and no patient should be commenced on long-term nebulised medication without assessment by a respiratory specialist to determine suitability for this treatment.
Acute management - COPD
- Patients should be assessed in accordance with Acute exacerbation guidance and referred as appropriate to the Community Respiratory service
- It is NOT appropriate to commence patients on home use of nebulised medication during an exacerbation or ' flare up' of their condition.
- See COPD exacerbation (Wakefield) Care Pathway
Long Term Nebuliser Use
All patients with a diagnosis of asthma using nebulised medication must be under the care of the Respiratory Specialist Team.
Commencing nebulised medication
- The advent of new inhaler devices has largely removed the need for nebulisers at home. Nebuliser therapy is expensive and can increase risk of infections if equipment is not cleaned and changed appropriately.
- NICE recommends specialist referral and assessment of patients with COPD in whom long term nebuliser therapy is being considered. Nebulised therapy may also be used in the treatment of conditions such as cystic fibrosis, bronchiectasis and infections in immunopromised individuals (eg pneumocystis).
- Patients having nebulised therapy should have access to a nebuliser service that includes specialist assessment of the need for nebulisers, equipment, servicing, advice and support.
- All patients potentially requiring long-term nebulised medication must first be discussed via e-consultation and referred to the Respiratory Specialist team for clear diagnosis, optimisation of medication and appropriate assessment. The patient should be referred for medicines optimisation and not nebuliser assessment, as a nebuliser may not always be found to be appropriate
- Requests for nebuliser provision in hospital discharge letters should result in a referral for medicines optimisation and not provision of nebulised medication in primary care without full assessment by an appropriate specialist
- Following appropriate assessment a compressor and nebuliser equipment will be provided through the Community Respiratory Service if shown to be beneficial.
- The service will include servicing, provision of consumables, 24 hour breakdown cover and regular medication reviews as recommended by NICE and BTS.
Patients already established on nebulised medication
The prescriber is responsible for ensuring that equipment used to deliver medication is safe and appropriately used.
Patients should not be advised to purchase their own equipment.
- Medication should not be provided to patients following purchase of their own equipment without appropriate assessment by a Respiratory Specialist.
- Patients using a compressor at home should undergo an annual review of equipment, medication and benefit. Equipment provided through the Community Respiratory Service will receive review as part of the service and should be advised of the need to attend when contacted.
- All Patients using a compressor at home should be asked to bring the equipment in to their review in the Practice or equipment reviewed at home for housebound patients as part of their annual review. This review should include use and care of the equipment, by an appropriately trained health professional.
- Patients purchasing their own compressor are responsible for purchase of consumables and servicing of equipment.
Annual Review of equipment should include
- Visual inspection of equipment for cleanliness, damage and appropriateness of delivery device, eg muscarinic antagonists (ipratropium ) must only be used with a mouthpiece and not a mask due to the risk of acute angle glaucoma
- Service history and advice re servicing timetable for those who have purchased their own equipment
- Consumable replacement advice
- Education of patient re use and care of equipment
- Actions in event of equipment failure, use of large volume spacer and provision
Nebulised therapy should not continue to be prescribed for patients with COPD without assessing and confirming that one or more of the following occurs:
- A reduction in symptoms
- An increase in the ability to undertake activities of daily living
- An increase in exercise capacity
- An improvement in lung function
Patients using their own equipment should be referred to Respiratory team via e-consultation for medicines optimisation assessment
Any concerns identified for patients using equipment provided through the Community Respiratory Service should be advised to contact 01924 541827 for further advice
Assurance & Governance
- This guidance was developed on: 03.2017
- This guidance was ratified by: The OSCAR Assurance Group
- Date ratified: 05.2017
- Publication Date: 05.2017
- Review Date: 05.2019
- Ref No: RS5 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: firstname.lastname@example.org
Only the electronic version is maintained, once printed this is no longer a controlled document
Care Pathways >
Nebulised Therapy Guidance (Wakefield)