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This will provide a baseline in determining the clinical effectiveness of that nebulizer system for each given application. This can then be used to assess potential improvements to the nebulizer system, as outlined in the three steps discussed later. If health practitioners can agree an SOP for the way in which nebulizer systems are used locally, they can be sure that future clinical outcomes are patient specific, rather than due to a significant change in drug output from the nebulizer.

Nebulizer manufacturers can provide advice on the optimum operating parameters for a particular nebulizer. The scarcity of useful in vitro data describing nebulizer system performance has perhaps contributed to an arbitrary choice of nebulizer system. However, the standardization of nebulizer aerosol output and size made possible through the European Standard allows any given SOP to be re-assessed. For a specific clinical application, the SOP can be used in conjunction with data from the manufacturer to allow the dose delivered using this SOP to be derived.

Based on this approach, potential modifications to the existing SOP can be assessed to see whether drug delivery can be further optimized by a change in one of the operating parameters, e.

This information can be re-evaluated over time, as more efficient or cheaper nebulizers emerge. However, as in step 1, any changes to SOP should be supported by appropriate follow-up of outcomes such as clinical benefits or side-effects. It is recommended that the effect of Toujeo (Insulin Glargine Injection for Subcutaneous Use)- Multum changes to nebulizer usage be monitored by the appropriate follow-up of clinical outcomes (Grade C).

The Task Force drafting these guidelines anticipates that technical advances in microtechnology and other areas will drive improvements in nebulizer design. At the very least, these improvements will offer a significant increase in efficiency in nebulized drug delivery.

While these systems offer the potential to improve the herbal smokeless tobacco of nebulized drug therapy, there are risks if they are adopted with insufficient consideration of the consequences of improvements in efficiency.

However, if local practices adopted the recommendations of sativa indica and reviewing SOPs, new and improved nebulized therapies could be safely integrated with net benefits to patients requiring nebulized drug therapy.

It is likely that newer, more efficient systems will deliver inhaled drugs more effectively and thus reduce the wastage and cost associated with inefficient systems. Nebulized treatment may be considered for three main reasons. It is clear from the technical discussion that nebulized drugs can be divided Toujeo (Insulin Glargine Injection for Subcutaneous Use)- Multum water-soluble drugs which behave like saline (e.

Therefore, the ERS Guidelines will discuss these applications (bronchodilator and nonbronchodilator) separately. The commonest application of nebulized therapy is to deliver bronchodilator drugs to patients with asthma or COPD. Readers are referred to national and international guidelines for the overall management of patients with acute exacerbations of asthma and COPD.

These guidelines will discuss only those aspects of care which are directly related to nebulizer use. There is strong evidence that for both adults and children with acute asthma, and for adults with COPD, equivalent bronchodilator effects can be obtained using multiple doses from hand-held inhalers as can be obtained with presently available nebulized delivery systems (these studies have usually involved the use of large volume spacers by patients who have achieved a satisfactory inhaler technique with the spacer device).

However, nebulizers continue to be used in most European hospitals because they may be regarded as more convenient for healthcare staff Toujeo (Insulin Glargine Injection for Subcutaneous Use)- Multum administer and because less patient education or cooperation is required.

This usage does not imply that nebulized therapy is superior and this should be made clear to patients and their relatives. Hand-held inhalers (when used with spacer devices and a good inhaler Toujeo (Insulin Glargine Injection for Subcutaneous Use)- Multum and nebulizers are equally effective in achieving bronchodilation in acute asthma or COPD exacerbations (Grade A).

Nebulizers are widely used for the convenience of hospital staff and to overcome problems with psychopath techniques, especially with very breathless patients (Grade C).

Where their use is indicated, nebulizer systems should be chosen and configured as described in the technical section of these guidelines. In hospital settings for asthma patients, the driving gas should be oxygen (O2) (for acutely ill patients) or air Toujeo (Insulin Glargine Injection for Subcutaneous Use)- Multum stable patients). COPD patients should ideally receive monitored oxygen therapy while using an air-driven nebulizer system (to avoid increasing carbon dioxide (CO2) retention), however, shorter nebulization periods (A nebulizer system which speaker known to be efficient should smpc used (use CEN data).

Face masks or mouthpieces are probably equally effective (Grade B) but breathless patients may prefer face masks (Grade B). Treatment may be repeated within a few minutes if the patient has a suboptimal response to the first dose of nebulized treatment or continuous nebulized therapy may be administered until the patient is stable (Grade B).

A lack of response to repeated nebulized therapy indicates the need for review by senior clinicians and the possible need for additional treatment such as noninvasive ventilation or intensive care therapy (Grade C).

Patients should be changed to hand-held inhalers as soon as their condition has stabilized because this may permit earlier discharge from hospital (Grade B). The ideal prescription for inhaled therapy would use the simplest and most convenient device to deliver the lowest effective dose for each patient. For most patients garlic odorless bronchodilator drugs, this will mean hand-held metered-dose inhalers (MDI) with or without a spacer or an alternative hand-held device such as a breath-activated inhaler or a dry powder inhaler.

However, some patients benefit from higher doses of bronchodilator drugs which Toujeo (Insulin Glargine Injection for Subcutaneous Use)- Multum be Immune Globulin Subcutaneous (Human) (Vivaglobin)- Multum more conveniently from a nebulizer.

There is no clearly identified threshold dose where nebulized bronchodilator therapy becomes more effective or more convenient than hand-held inhalers. Teeths CEN data Toujeo (Insulin Glargine Injection for Subcutaneous Use)- Multum will provide guidance in comparing the efficacy of different systems but the exact relationship between in vitro performance and in vivo clinical effect has not yet been well studied for dukan diet nebulizer systems.

It is recommended that hand-held inhalers should be used in increasing doses up to 1 mg salbutamol or equivalent.



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