Are nebulisers about to be smashed into obscurity?

Pharmacists should brace for yet another medicine shortage, with Ventolin Nebules (salbutamol sulfate) 2.5 mg/2.5 mL set to be in scarce supply from 16 October 2023, the Therapeutic Goods Administration has warned. However, this shortage might actually be beneficial for patients.

GlaxoSmithKline is anticipating a ‘worldwide out-of-stock period’ of the 2.5 mg salbutamol sulfate nebule, mostly used by children, until 24 June 2024, due to a manufacturing disruption. 

However, the shortage is a huge opportunity to improve asthma control – setting the nation’s youngest up for a future of better asthma management, according to Debbie Rigby FPS, Clinical Executive Lead at the National Asthma Council Australia.

While there is no shortage of Ventolin Nebules 5.0 mg/2.5 mL, there is ‘a risk we may also create a shortage of [this strength], because people will use it instead of the 2.5 mg dose’, she said.

‘Patients who have used nebulisers in the past have just continued to do so, whereas the evidence just doesn’t support it,’ she added.

Guidelines suggest using a pressurised metered dose inhaler (pMDI) with a spacer is just as effective, if not more effective, than using a nebuliser. 

‘The Pharmaceutical Benefits Scheme restricts [salbutamol sulfate] to people who are unable to use a pMDI and a spacer,’ said Ms Rigby. ‘The reality is that virtually everyone can use a pMDI with spacer effectively – including with a mask where required.’

The benefits of ceasing nebulisation

There are a number of reasons why pharmacists should use this medicine shortage to help make nebulisers a relic of the past, including that they:

• require a power source to run, making them less portable
• take a longer time to deliver a dose of salbutamol, with patients needing to wait up to 10 minutes for the dose to be administered
• are not user friendly, requiring a degree of dexterity and cognition to measure out nebulising solution and place them into the nebuliser.

Nebuliser use also poses an infection risk, and is thought to have spread COVID-19 through Melbourne’s hotel quarantine via airborne droplets. ‘During the height of the pandemic, patients were even [warned] not to use nebulisers,’ said Ms Rigby. 

In fact, salbutamol sulfate is rarely included in hospital formularies these days, with many opting not to use them in emergency departments, for example.

‘Hospitals tend to use spacers, because they are just as effective and easier to use,’ Ms Rigby said.

There is one exception to the rule, however. 

‘There is a small place for nebulisers in intensive care units when patients’ breathing is very compromised,’ she said. ‘But the vast majority of people in the community, including when they are experiencing exacerbations of asthma or chronic obstructive pulmonary disease, should be using a pMDI and a spacer.’

Practice tips for pharmacists

To ensure patients and carers have sufficient time to rethink asthma reliever treatment in the wake of salbutamol nebule shortages, pharmacists should be keep an eye out for those who:

• come into the pharmacy with a script for salbutamol sulfate nebules
• are purchasing equipment such as nebuliser tubing or bowls
• ask to buy a nebuliser.

‘It’s an opportunity to confirm diagnosis, assess control, optimise therapy, assess adherence and inhaler technique, and update written action plans,’ said Ms Rigby. 

‘using a pressurised metered dose inhaler  with a spacer is just as effective, if not more effective, than using a nebuliser.’ 

This includes educating patients about using a pMDI and a spacer, with children younger than 4 years of age, or those who cannot seal their lips tightly around the mouthpiece, advised to use a tightly fitted face mask attached to the spacer.

Pharmacists should highlight the numerous benefits of this reliever approach, including:

• smaller doses, ensuring less potential for systemic absorption, and fewer potential side effects such as tremor and heart palpitations
• a long-term cost saving.

Enquiring how often patients use nebulisers can also provide insight into their asthma control.

‘People tend to use nebulisers when they’re having a flare-up,’ said Ms Rigby. ‘If that’s happening too often, it indicates they don’t have good control of their asthma.’ 

A good place to start is by emphasising that all adults and adolescents with asthma should be taking a preventer medicine. Patients who present with scripts for nebules should be referred back to their GP for an asthma review.

‘We know adherence to preventers isn’t great, so it’s about having a conversation with patients or their parents about the importance of using these medicines to prevent future exacerbations and ensure good asthma control,’ she said.

Moving away from salbutamol

The shortage of nebules should trigger a more in-depth conversation about the dangers of over-reliance on salbutamol, which can result in poor or partial asthma control, manifesting in more frequent wheezing, coughing and shortness of breath.

To gauge patients’ level of asthma control, pharmacists should assess whether their condition is:

• impacting day-to-day activities 
• preventing them from attending work, school or exercising
• causing them to wake up symptomatic in the middle of the night or early morning.

‘You should reinforce the message that good control of asthma means not using salbutamol more than twice a week,’ said Ms Rigby. 

While patients should only use two salbutamol canisters a year, ‘many people use far more than that’, and are underusing preventers such as inhaled corticosteroids. 

‘Salbutamol gives very quick and effective control of asthma symptoms,’ she said. ‘But it does nothing for the underlying inflammation associated with asthma.’