Inhaled Medication Administration (MDI, Spacer & Nebulizer)

Inhaled drugs work only when they reach the airway. Use a spacer with one puff at a time, or run a nebulizer until the mist stops, and reassess before any repeat dose.

Inhaled bronchodilators relax airway smooth muscle right where they land. A small dose is enough, because it goes straight to the target. Most of it never gets there, though. It stays in the device, the mouth or the circuit. How much arrives depends on the device, the patient's breathing and, when ventilated, the circuit.

How It Works

• Beta-2 agonists: albuterol (salbutamol) relaxes bronchospasm. You repeat the dose by response. In an attack there's no fixed schedule.
• Anticholinergic: ipratropium adds bronchodilation in moderate to severe attacks. It doesn't replace a beta-2 agonist.
• Delivery route: Adults get similar lung function gains from an MDI with spacer or from a nebulizer (per GINA 2026). The spacer wins on efficiency and costs less per patient.
• Ventilator circuit: where the device sits in the circuit changes how much drug reaches the lung. So does the device itself.

Where It Fits

For most children, GINA picks pMDI with spacer over a nebulizer. The spacer is more efficient and more comfortable, and it avoids spreading respiratory viruses. The nebulizer stays the choice in two cases. The patient can't use a spacer, or oxygen is needed to drive the mist.

Indications

• Bronchospasm with wheeze and increased work of breathing from asthma or COPD exacerbation
• Bronchospasm in a ventilated patient, delivered in-line (per protocol); BVM and CPAP in-line use are not covered here
• Bronchospasm with anaphylaxis: a bronchodilator is an adjunct only, after IM epinephrine
• Croup or post-extubation stridor: nebulized epinephrine, covered on the racemic epinephrine page

Absolute Contraindications

• Known hypersensitivity to the drug or any product component (albuterol and ipratropium labels)
• Ipratropium: hypersensitivity to atropine or its derivatives (label)

Relative Contraindications & Cautions

• Cardiovascular disorders, arrhythmias or sympathomimetic sensitivity: beta-agonists may cause tachycardia and arrhythmia (albuterol label).
• Non-potassium-sparing diuretics may make hypokalemia and ECG changes worse. Digoxin levels may fall too (albuterol label).
• Narrow-angle glaucoma: ipratropium in the eyes can worsen it. The label says a mouthpiece may be the better choice over a face mask (ipratropium label).
• Hypercapnia risk (COPD): an oxygen-driven nebulizer can make CO₂ retention worse (per BTS 2017).
• Beta-blockers blunt the effect of albuterol. Non-selective agents may provoke bronchospasm (albuterol label, mutual inhibition).
• MAOIs or tricyclic antidepressants, including use within 2 weeks of stopping them, may boost albuterol's vascular effects (albuterol label).

Consider an Alternative

• IM epinephrine first when anaphylaxis is present, then the bronchodilator (epinephrine IM)
• Noninvasive ventilation or intubation when the patient tires or cannot maintain oxygenation (Noninvasive Ventilation, Intubation)
• IV magnesium for severe asthma in patients 2 years and older (Magnesium Sulfate)

Stop Criteria

• Paradoxical bronchospasm: stop the drug and switch therapy (albuterol and ventilator labels)
• Hypersensitivity reaction to the drug or a component: stop and treat per protocol

Escalate, Do Not Stop

• SpO₂ below 92% on oxygen, or a silent chest, with no response: escalate per protocol. A low SpO₂ means more oxygen and escalation. It doesn't mean stopping (GINA 2026: failure to respond at 1 hour, or SpO₂ below 92%, prompts admission and/or IV magnesium).
• Drowsiness or confusion in asthma is life-threatening. Treat it immediately.

Team Roles During the Procedure

• Operator: sets up the device and gives the dose
• Monitor: work of breathing, SpO₂, heart rate and rhythm, and waveform EtCO₂ when ventilated
• Recorder: drug, dose, device, time of each set and response

Patient Check

• Severity: adult severe features per GINA 2026: unable to speak, drink or lie down; SpO₂ below 92%; respiratory rate above 30/min; silent or quiet chest; PEF or FEV₁ below 50% predicted
• Life-threatening features: drowsiness, confusion, cyanosis or silent chest; treat immediately and call for help (per GINA 2026)
• Age and size: spacer with mask under about 5 years; nebulizer dose and concentrate chosen by weight under 15 kg (albuterol label)
• Current drugs: recent beta-agonist doses and frequency, oral steroids, diuretics, digoxin, beta-blockers (especially non-selective), and MAOIs or tricyclic antidepressants within 2 weeks
• Baseline: SpO₂, respiratory rate, heart rate, mental status and, if ventilated, EtCO₂ and peak pressure before the first dose

Physiologic Risk

Severe asthma can fail inside an hour. Repeated beta-agonist doses bring their own trap: toxicity that looks like worsening asthma. Check potassium and rhythm when you repeat them. In COPD with hypercapnia risk, the drive gas changes the risk of CO₂ retention (see Medications & Settings).

Device Check

• MDI: check the dose counter, prime a new or dropped inhaler (4 sprays into the air), and confirm the canister matches the chart
• Nebulizer: unit-dose vial, compressor or oxygen source, tubing and cup; confirm the driving gas before the drug is added

Equipment

Sizing

• Adult: standard mouthpiece or facemask; full dose on one MDI or nebulizer vial
• Child 5 years and under: spacer with face mask; one puff at a time with 5–6 breaths
• Child under 15 kg: doses under 2.5 mg use the 0.5% concentrate (albuterol label); check the weight-based dosing page

Patient Positioning & Preparation

Sit the patient upright, shoulders relaxed. Walk them through the breathing pattern before the first puff. A child who can't follow that pattern needs a mask fitted before any dose.

Treat these as reference doses. Check them against local protocol and the current drug label. Doses vary by protocol; follow local protocols and medical direction.

Oxygen and Driving Gas

Phase 1: Prepare

1. Confirm drug, puffs and dose: state the drug, number of puffs or mg, and product aloud; check the label.
2. Prime and shake: shake the inhaler before every puff. Prime a new or dropped MDI by releasing 4 sprays into the air.
3. Attach the spacer: insert the MDI into the spacer; add a face mask for a child 5 years and under if the mouthpiece is not held.
4. Set the nebulizer: place the vial in the cup and connect it to the set driving gas; confirm the flow before the cup is used.

Phase 2: Perform

5. Seal and breathe: the patient seals the lips on the mouthpiece (or the mask fits the face) and takes one puff.
6. Breathe from the spacer: 5–6 calm breaths after each puff; if the patient cannot hold one breath, use tidal breathing (per GINA 2026).
7. Repeat by severity: mild, 4 puffs; moderate, 4–6 puffs; severe, 6–10 puffs, one at a time.
8. Nebulize to dryness: run the nebulizer until mist stops, usually 5–15 min for 2.5 mg, with a mouthpiece if ipratropium is given.

Phase 3: Confirm & Secure

9. Start the timer: record the time, number of puffs or nebulizer end time, and the drug.
10. Reassess: work of breathing, speech, wheeze, respiratory rate, SpO₂ and heart rate (see Confirmation & Monitoring).
11. Repeat only by protocol: use the interval for the severity and stop if no response; escalate rather than repeat by default.

Alternative Technique: In-Line Delivery on a Ventilator

This page doesn't cover BVM, CPAP or NIV in-line technique, and no verified source was retrieved for it. Ventilator placement and dose follow the ventilator manual and local protocol.

12. Place the device on the inspiratory limb: An MDI with spacer goes on the inspiratory limb, ahead of the Y-piece. Where a nebulizer sits depends on the device type (see the device label and ventilator manual).
13. Avoid continuous nebulization by default: Continuous flow above the patient's inspiratory flow causes dyssynchrony. The added flow can read as minute volume, so hypoventilation may not alarm.
14. Use a spacer, not an elbow: On ventilator models, an MDI with spacer delivered several times more drug than an MDI at a connector, or an in-line device with no chamber.
15. Watch the circuit: check tidal volume, pressures, EtCO₂ and alarms during and after each dose; stop if dyssynchrony occurs.

Primary Confirmation

Look for real improvement on reassessment. Breathing gets easier. The patient speaks in longer phrases, uses less accessory muscle and holds SpO₂ in target. One good set doesn't earn a stop. Reassess after every set.

Secondary Confirmation

• Air entry and wheeze on auscultation, when the chest is audible
• Respiratory rate falling toward normal for age
• Heart rate and rhythm stable after repeated doses
• Ventilated: waveform EtCO₂ present, pressures and volumes stable

Ongoing Monitoring

• Continuous SpO₂; capnography when ventilated or when the patient is drowsy
• Reassess 20–30 min after each set, and review at least hourly in an ongoing attack (per GINA 2026)
• Potassium and ECG when repeated beta-agonist doses are given

Pediatrics

• Spacer: under about 5 years, use a spacer with face mask; give one puff at a time with 5–6 breaths after each (per GINA 2026)
• Nebulizer dose: the albuterol label gives 2.5 mg for children 15 kg and over; under 15 kg, doses under 2.5 mg use the 0.5% concentrate
• Label gap: The US albuterol 0.083% nebulizer label starts at age 2 years, so use under 2 is off-label. The US Ventolin HFA label says safety and effectiveness under 4 years are not demonstrated. GINA 2026 still uses spacer doses for 5 years and under in acute asthma. Medical direction sets the protocol.
• Ipratropium: 0.25 mg for 5 years and under (GINA); off-label under 12 per the US label; see the ipratropium page for age cut-offs
• Other pages: pair this with weight-based dosing, pediatric vital signs and croup. This page doesn't treat bronchiolitis (1–23 months). For that, go to bronchiolitis

Older Adults

• Beta-agonists can drive tachycardia and arrhythmia. Check rhythm before and after repeated sets (albuterol label caution).
• Digoxin and diuretics stack extra arrhythmia and potassium risk on top. Check potassium when doses repeat.

Pregnancy

• Treatment: GINA 2026 says to manage acute asthma in pregnancy aggressively. That means SABA, oxygen and early systemic corticosteroids, to avoid fetal hypoxia. Pregnant patients may get less appropriate treatment than non-pregnant ones.
• Oxygen: NAEPP EPR-3 (2007) aims for SaO₂ above 95% in pregnant women. GINA 2026 sets no separate target.
• Albuterol label: Pregnant patients with asthma should be watched closely, and the medication adjusted as necessary.
• Ipratropium label: Animal studies showed no teratogenic effect. Even so, use ipratropium in pregnancy only if it's clearly needed.

Physiologically Difficult

• COPD with hypercapnia risk: Drive the nebulizer with air or ultrasound. Keep oxygen at 88–92% with continuous oximetry (per BTS 2017).
• Ventilated patients: In the circuit, an MDI with spacer is more efficient than an elbow connector. Avoid continuous nebulization by default.
• Severe presentation: Transfer and treatment start now. Don't wait for a full assessment.

Immediate Aftercare

• Reassess at 20–30 min after the last set, and review at least hourly while the attack continues (per GINA 2026)
• Keep SpO₂ monitoring until the patient is stable on the planned route
• Return the oxygen to the usual device once the nebulizer is finished (per BTS 2017)

Ongoing Maintenance

• Clean the nebulizer per its label after use; do not reuse single-dose vials
• Follow the manufacturer on washing or priming. Some spacers need a detergent pre-wash, or 2–4 priming puffs, because of static charge (per GINA 2026).
• Cap the MDI between uses; read the dose counter at handoff

Transport Considerations

• Set the nebulizer's oxygen before the vehicle moves. A flow that drops stops the mist.
• Reassess after every move. Masks and circuits can slip in transport.
• When noise or vibration hides the work of breathing, trust SpO₂, EtCO₂ and the monitor.
• Ventilated: keep in-line devices on the inspiratory limb; re-check after every move

Pearls

• Breath is the delivery: take one puff, then breathe 5–6 breaths from the spacer (per GINA 2026).
• Spacer for most children: For most children, GINA picks pMDI with spacer over a nebulizer.
• Ventilator circuit: in the cited studies, a spacer in the circuit delivered several times more drug than an elbow connector.
• Combine in one nebulizer: ipratropium can go in the same nebulizer as albuterol, provided it's used within one hour (ipratropium label).
• Mouthpiece for ipratropium: a loose mask sends mist into the eyes.
• Air-driven in COPD: in hypercapnic patients, oxygen-driven nebulizers carry a risk of CO₂ retention (per BTS 2017).

Common Pitfalls

• Puffs as mg: 100 mcg per puff (GINA) and 90 mcg per puff (US label) come from different products. Name the product.
• Repeat by default: reassess before every set. No response at one hour? Escalate.
• Continuous in-line nebulizer: hypoventilation can go unseen if nobody checks the bias flow and the alarms.
• Quiet chest read as better: a silent chest in asthma is a severe sign. Not an improvement.
• Oxygen-driven nebulizer in COPD: long sets at high flow, with no SpO₂ monitoring, put the patient at risk of hypercapnia.

Skill Maintenance

• Practice the spacer breath pattern on a simulator: one puff, then 5–6 breaths, with a mask fit for a child.
• Run a checklist drill: product, puffs, driving gas, mouthpiece versus mask, and reassessment time.
• Simulate an in-line dose on a ventilator circuit, and debrief the alarms and the timing.
• Check the spacer and nebulizer kit at each shift or unit inspection; replace worn or cracked parts.