How to give treatment to patient on BiPAP

I find that many respiratory therapists where I work insert the breathing treatment between the machine and the circuit.  When I ask whey they do this, they say the treatment is not indicated anyway.  They promise me when the treatment is indicated they place the nebulizer between the patient and the Y-connector.

Okay, this is fine.  And I agree that it's much easier to give a breathing treatment at the machine, especially if the patient is sleeping.  Yet if you are going to be using science here, and Lord knows we'd like physicians to base what they order on science, we ought to do the same.

Claude Guerin, et all, "Inhaled Bronchodilator Administration During
Mechanical Ventilation: How to Optimize It, and For Which Clinical Benefit?, Journal of Aerosol Medicine and Pulmonary Drug Delivery, (Volume 21, Number 1, 2008), notes the following:

With the bilevel ventilators the inhalation device should be located between the leak
port and face mask. Further studies should investigate the effects of inhaled bronchodilators on patient outcome and methods to optimize delivery of inhaled bronchodilators during noninvasive ventilation.

So while further research is needed, common sense should indicate a significant amount of the aerisolized medication would impact on the circuit, and this would be greater with longer circuits.  So it only makes sense to insert the breathing treatment closer to the patient.

Yet in a world where 80 percent of the breathing treatments are not indicated anyway, it's far easier for RTs to do the treatment the easy way, or to put it by the machine.  Yet I highly recommend you only do this when the treatment is truly not indicated.  If you don't know for sure, you're wise to do it the right way.