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MARY BETH SHIRK, PHARM.D., is Specialty Practice Pharmacist, Critical Care, and Clinical Assistant Professor, Department of Pharmacy, The Ohio State University Medical Center (OSUMC), Columbus. KEVIN R. DONAHUE, B.S. and Pharm.D. degree candidate, is Pharmacy Intern, OSUMC. JILL SHIRVANI, A.A.S, is Registered Respiratory Therapist, OSUMC.

Address correspondence to Dr. Shirk at the Department of Pharmacy, The Ohio State University Medical Center, Room 368, Doan Hall, 410 West 10th Avenue, Columbus, OH 43210-1228 (marybeth.shirk{at}osumc.edu).

Purpose. The uses, dosing recommendations, benefits, and disadvantages of unlabeled drugs administered by nebulization are reviewed. Summary. Nebulization is gaining popularity as a treatment alternative, and many drugs are used unlabeled in a nebulized form, including the opioids, lidocaine, magnesium sulfate, amphotericin B, and colistin. The opioids are frequently used to treat dyspnea in end-stage diseases. Common dosages include 1–2 mg every two hours as needed for hydromorphone and 25–50 µg every two hours for fentanyl citrate. Lidocaine can be used to relieve bronchoconstriction and cough symptoms as well as acting as a local anesthetic. It is typically given in a dose between 20 and 160 mg. Nebulized magnesium sulfate can be used in managing acute asthma and is given in dosages between 125 and 250 mg every 20 minutes, with no more than four consecutive doses. Nebulized amphotericin B can be used to prevent infections in immunocompromised patients. A typical amphotericin B regimen is 25 mg every 24 hours. Nebulized colistin is being studied in the prevention and treatment of gram-negative infections and in patients awaiting lung transplants. Colistin is often given as 75 mg every 12 hours to combat infections. Conclusion. Unlabeled nebulization of opioids, lidocaine, magnesium, amphotericin B, and colistin is an alternative method of treatment for patients with pulmonary problems or infections or for those undergoing bronchoscopy. More research is needed to develop guidelines for their use since nebulization may provide benefits to many patients who otherwise cannot be treated or would be at risk of systemic adverse effects of the drugs. Index terms: Aerosols; Amphotericin B; Anesthetics, local; Anticonvulsants; Antifungals; Antiinfective agents; Colistin; Dosage; Drug administration routes; Drug use; Fentanyl; Hydromorphone; Lidocaine; Magnesium sulfate; Nebulizers; Opiates; Protocols; Toxicity