The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [549]
Equipment
Nebulizer
The advantage of nebulizers is that they can deliver more drug to the lungs than standard inhalers because of the smaller particles that are generated. They also do not require any co-ordination in order to deliver the drug to the lungs. The disadvantages are that they are expensive, they are not easily portable and the delivery of drug can be difficult to control, for example due to loss in the tubing and mouthpiece.
Metered dose inhaler (MDI)
The advantages of MDIs are that they are convenient, can deliver a fixed dose and are inexpensive. The disadvantage can be the co-ordination needed to use one. In order to be effective, the patient needs to trigger the MDI during a deep slow inhalation and then hold their breath for around 10 seconds. This need for co-ordination between actuation of the dose and inhalation can be removed by using a spacer device (Figure 13.13). The spacer device reduces the speed with which the dose is delivered and the resultant ‘cold freon’ effect that can occur, which can prevent a patient from continuing to inhale after actuation of the MDI. Spacers are also useful for patients on high-dose inhaled steroids in order to prevent oral candidiasis, children and patients requiring higher doses, and can improve dose delivery to 15% (Downie et al. 2003). Spacer devices are designed to be compatible with specific inhalers and therefore care should be taken to ensure the correct spacer device is used.
Figure 13.13 Spacer device.
Medication in MDIs is under pressure and so they should not be punctured or stored near heat or in hot conditions (e.g. patients must be taught not to leave their MDI in a hot car) (Chernecky et al. 2002).
Dry powder inhaler (DPI)
Dry powder inhalers are also useful when there are problems with co-ordination. However, they can initiate a cough reflex and patients need to have sufficient breath inhalation to activate the device.
It is also important to remember that because these medications are absorbed rapidly through the pulmonary circulation, most create systemic side-effects (Chernecky et al. 2002, Snyder 2007).
Specific patient preparations
Patients who suffer from chronic respiratory disease and require airway management frequently receive inhalational medications. Maximum benefit is obtained only when the correct technique of inhalation is used so it is vital that patients are taught how to use these devices correctly and safely. Periodic checks should be carried out to ensure that efficiency is being maintained. Use of a MDI requires co-ordination during the breathing cycle and impairment of grasp or presence of tremors of the hands interferes with patient ability to depress the canister within the inhaler (Chernecky et al. 2002, Snyder 2007). Studies have shown that both adults and children have difficulties with aerosol inhalers and problems include co-ordinating activation and inhalation, too rapid inhalation and too short breaths after inspiration (Hilton 1990). Baseline observations of pulse, respirations and breath sounds should be performed before beginning treatment to use as a comparison during and after treatment (Snyder 2007). Patients who are to receive nebulized medicines should be in a sitting position either in bed or a chair (Downie et al. 2003).
Education
Compliance is more likely to be achieved if the patient is well informed. It is the responsibilty of the nurse, doctor and pharamcists to ensure that patients have adequate teaching and demonstration and are monitored at intervals. Downie et al. (2003) suggest that the patient should know the following.
About the disease, the purpose of the therapy, how to recognize and report deterioration in the condition.
How to use and care for the inhaler.
The dose to be taken.
The time interval.
The maximum number of inhalations which should be taken in 24 hours.
Procedure guideline 13.7 Medication: administration by inhalation using a metered dose inhaler
Essential equipment
MDI device
Spacer device
Preprocedure
Action Rationale
1 Explain and discuss the procedure