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India: Inhalation therapy remains a cornerstone in the treatment of obstructive, inflammatory, and infectious respiratory diseases, with inhalers often being a physician’s go-to device. However, their effectiveness is frequently compromised due to poor adherence and incorrect usage. Studies show that 30–60% of asthma patients and up to 80% of COPD patients commit at least one critical error while using inhalers. A cross-sectional study also found that 75.36% of patients made errors regardless of inhaler type, leading to poor disease control and increased risk of exacerbations.

In this context, nebulization has emerged as a valuable alternative for delivering bronchodilators and corticosteroids. Despite its clinical relevance, existing nebulization guidelines are lengthy and challenging to use in routine practice.

To address this gap, an expert panel of leading Indian pulmonologists have developed a simplified, evidence-based guidance document titled the NOVA-ER, an Expert’s Review, published in the Medical Research Archives. This document provides practical recommendations for managing Asthma, COPD, Bronchiectasis, and overlapping respiratory conditions, addressing both rescue and maintenance therapies tailored to disease severity.

The panel based their recommendations on an extensive review of recent peer-reviewed literature and clinical guidelines using databases like PubMed, MEDLINE, and the Cochrane Library. Structured discussions among pulmonology experts further refined the guidance.

The NOVA-ER article presents stepwise, disease-specific algorithms (e.g., COPD Treatment algorithm as given below) to support clinicians in selecting appropriate nebulized treatments and highlights the use of nebulizer therapy in suitable candidates, ultimately aiming to improve implementation of nebulization therapy in India’s respiratory care framework.

Fig 1: Algorithm for the use of nebulization and advice on home nebulization in COPD

Here are the insights from the consensus:

1. Inhalers should continue to be used as the first-line therapy, while nebulizers are essential for specific patient groups requiring easier administration or higher-dose medication.
2. Nebulized LAMA, like glycopyrrolate, significantly enhances lung function and quality of life in COPD patients, offering consistent benefits regardless of chronic bronchitis status.
3. Nebulizers are recommended in emergency settings for treating acute COPD exacerbations, especially with SABA or SAMA, either alone or in combination.
4. For those with frequent exacerbations of COPD, triple therapy with LABA, LAMA, and ICS (e.g., formoterol, glycopyrronium, and budesonide) is strongly recommended, particularly for patients with high eosinophil counts.
5. Nebulization is very important in asthma management, especially when a patient has severe symptoms, is not responsive to inhalers, has not responded well to metered dose inhalers, and requires a high dosage of the medication, including children.
6. Home nebulization with budesonide is equally effective as budesonide via inhaler, a valuable option for managing persistent asthma.
7. For moderate to severe asthma, the combination of LABA and ICS, particularly formoterol/budesonide, is the preferred first-line treatment and is highly effective in both maintenance and reliever asthma therapy.
8. Rescue therapy for patients admitted due to exacerbations of asthma may use fix combinations such as SABA + SAMA, i.e., levosalbutamol and ipratropium, or LABA + LAMA / ICS formoterol and glycopyrronium or budesonide, supporting both emergency and home nebulization strategies.
9. According to currently available guidelines on bronchiectasis, the stepwise management of bronchiectasis focuses first on airway clearance and pulmonary rehabilitation before using nebulized antibiotics, which is critical in the management of the condition.
10. Nebulized antibiotics, including tobramycin and colistin, are encouraging in bronchiectasis with chronic P. aeruginosa infection, especially tobramycin, which can reduce the bacterial load and increase time to P. aeruginosa recurrence.
11. Nebulized hypertonic saline (HS) and NAC are effective mucoactive agents that enhance mucociliary clearance and reduce exacerbations in patients with bronchiectasis, enhancing patient prognosis.
12. Inhaled tobramycin and colistin show efficacy in the management of bronchiectasis; however, patient-specific factors such as disease severity and therapeutic education are critical to minimizing side effects and ensuring treatment adherence.
13. Administration of long-term inhaled antibiotics and NAC has been found to decrease the frequency of exacerbations in bronchiectasis; therefore, it should be considered an essential component of bronchiectasis management.
14. To manage ACOS (Asthma phenotype), the use of ICS + LABA combinations should be preferred since evidence suggests that LABA alone is less effective in reducing hospitalization and mortality.
15. In Bronchiectasis-COPD Overlap Syndrome, inhaled corticosteroids should be used cautiously due to their potential to increase bacterial load, highlighting that further research needs to be conducted to establish the best approach to managing this overlap syndrome.
16. In patients with both bronchiectasis and asthma, there should be a proper assessment for fungal pathogens, and management plans should include anti-fungal treatment if fungal infection is detected as well as oral steroids and long-term macrolide therapy for eradication of bacterial and fungal infection.
17. Nebulization is necessary for providing bronchodilators and antibiotics for patients with critical illnesses, and mechanical ventilation with synchronization to ventilation providing better therapeutic effects.
18. Nebulized antibiotics, such as colistin, are recommended as an essential strategy in the management of ventilator-associated pneumonia caused by multidrug-resistant gram-negative pathogens, achieving high intra-pulmonary concentrations effectively.

Experts highlight the importance of thorough patient education. Guiding patients on proper maintenance, cleaning, and disinfection of nebulizers is crucial for ensuring hygiene and effective device performance. In addition, patient counseling is vital for enhancing adherence to prescribed nebulizer therapy, which supports consistent medication use and helps achieve better long-term health outcomes.

Reference: Dhar, R., Mukhopadhyay, A., et al., 2025. Nebulization Optimization for Management of Obstructive Airway Disorders: An Expert Review (NOVA-ER). Medical Research Archives, [online]13(4).https://doi.org/10.18103/mra.v13i4.6377