Practice of nebulization in intensive care unit patients receiving invasive ventilation - A nationwide survey

Nebulization with mucolytic and bronchodilator agents is frequently applied in Intensive Care Units (ICUs) for invasively ventilated patients, despite limited evidence for clinical benefit and potential risks associated with routine use. Understanding current practice and rationale behind nebulization is essential to targeted de-implementation strategies.

We conducted a nationwide, cross-sectional telephone survey among ICU healthcare professionals in the Netherlands. The survey addressed nebulization practices for mucolytics and bronchodilators, including agents used, administration strategy, clinical indications, evaluation strategies, and local protocols. Open-ended questions explored underlying clinical reasoning and factors influencing nebulization practices.

Representatives from 54 of 71 Dutch ICUs (76%) participated. Most respondents were ventilation practitioners (72%, 39/54), supplemented by ICU nurses and intensivists. Nebulization with mucolytics was reported in 47 ICUs (87%) ICUs and with bronchodilators in all ICUs. On-demand nebulization predominated (91.5%, 43/47 for mucolytics; 83.3%, 45/54 for bronchodilators). Thick secretions were the main indication for mucolytics, whereas obstructive pulmonary disease and bronchospasm were leading indications for bronchodilators. Acetylcysteine and salbutamol/ipratropium were most frequently used. Local protocols were present in 41 (76%) ICUs. Active humidification was commonly applied on indication, particularly in prolonged ventilation. Responses to open-ended questions revealed that, beyond clinical triggers, nebulization decisions were frequently shaped by personal preference, habitual practice, and organizational context, rather than by evidence-based reasoning.

Nebulization in Dutch ICUs is predominantly on-demand but practice remains variable and partly driven by ingrained habits instead of evidence. Non-indicated nebulization persists and represents potential low-value care.

This nationwide survey demonstrates that nebulization practices in Dutch ICUs remain highly variable, often driven by non-standardized protocols and subjective interpretation of indications rather than evidence. To promote more consistent and evidence-based care, implementing a practical decision-support tool could guide clinicians toward indication-based nebulization and support de-implementation of routine, non-indicated use.