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Recommendations for Nebulizer to Metered Dose Inhaler Interchange in SHA Acute Care Facilities

Key Messages:

  1. Meter Dose Inhalers (MDIs) are preferred over nebulization
  2. MDI stock is limited – assessment if a MDI is required for non-Influenza Like Illness (ILI) patients

To reduce the risk of transmission via droplets and aerosols, the pharmacy department in SHA acute care facilities will substitute all newly ordered nebulized medications that have metered dose inhaler (MDI) equivalents.  

  • The use of MDIs is shown to be as effective as nebulization. In addition, MDIs reduce the generation of aerosol particles, expedite treatment and require less staffing resources, but most importantly ensure safety. The use of MDIs instead of nebulizers has been written into the Work Standard when patients with ILI symptoms present to our acute care emergency departments.

  • Nebulized medications will be restricted to the following:
  1. Severe life-threatening respiratory disease which may include end-stage COPD and cystic fibrosis
  2. Patients unable and uncooperative to use MDI.  Isolation measures are required

Dosing conversions are as per table 1. This will be implemented as an automatic therapeutic substation effective immediately, during and following resolution of the COVID-19 pandemic.  

In the event that a nebulizer is required, the prescriber must specifically specify in the written order that a nebulized solution is required (eg. no sub).

Table 1: Nebulizer to Metered Dose Inhaler (MDI) Conversion

 Drug Name
Nebulized Dose  MDI Drug Equivalent  MDI Equivalent Dose 
 Salbutamol 1 mg/mL (2.5 ml)
2.5 mg = 1 nebule  
2.5 mg Salbutamol 100 mcg/puff  2 puffs
Ipratropium 0.25 mg/mL 
0.5 mg (500 mcg) = 2 mL = 1 nebule
1 neb Ipratropium 20 mcg/puff  2 puffs
(ipratropium/salbutamol 0.5 mg /2.5 mg) = 1 nebule
1 neb Combivent Respimat® 
(ipratropium/salbutamol 20 mcg/100 mcg)/puff 
1 puff
Budesonide 0.5 mg/mL (2 mL) 1 mg = 2 mL = 1 nebule 1 neb - Fluticasone propionate 125 mcg/puff  2 puffs

Metered dose inhalers are for individual patients and must never be shared. They are to be labelled patient-specific and stored in a patient-specific location. Once the inhaler order has been discontinued or the patient is discharged, the inhaler must be properly disposed of.  Inhalers may be sent home with the patient if they are ordered on discharge.

Newhouse, Michael T. “RE: Transmission of Corona Virus by Nebulizer- A Serious, Underappreciated Risk” CMAJ, 4 Mar. 2020,

RE: Transmission of Corona Virus by Nebulizer- a serious, underappreciated risk!

Practices to minimize aerosolizing procedures for patients on droplet precautions. 

Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com.

S.A. Alhaider, H.A. Alshehri, K. Al-Eid. Replacing nebulizers by MDI-spacers for bronchodilator and inhaled corticosteroid administration: Impact on the utilization of hospital resources. International Journal of Pediatrics and Adolescent Medicine,Volume 1, Issue 1, 2014,Pages 26-30

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