“Administration of Inhaled Medications”  by Craig Smallwood for OPENPediatrics
15
October

By Adem Lewis / in , , , , , , , , , , , , , /


Administration of
Inhaled Medications, by Craig Smallwood. My name is Craig Smallwood. I’m a Respiratory
Therapist and a Researcher here at Boston
Children’s Hospital. Today, we’re going to
discuss administration of inhaled and
nebulized medications. More specifically, we’ll
review small volume nebulizers and, specifically,
metered dose inhalers. A nebulizer is a device used
to administer medication in the form of a
mist or an aerosol. There are many different
types of nebulizers, and I’m going to describe
only a few today. All of nebulizers, on the other
hand, take gas– typically air. Gas, usually oxygen
or perhaps Heliox, which is mixed with a liquid
suspension medication and then forms an aerosol for delivery
to the patients within the lungs themselves. Most appropriately
performing nebulizers will produce particle
sizes in the two to three micron range, which will
ensure adequate delivery to an appropriate portion
in the respiratory tract. Indications and
Contraindications. Indications for
inhaled medication are to treat or reverse
bronchospasm, inflammation, thick secretions, airway
infections, airway edema, airway anesthetization,
sputum induction. Some common drug classes
that are administered by aerosol inhalations are– bronchodilators, used to treat
bronchospasm as seen in asthma. Steroids, used to
treat inflammation as seen in asthma and or
bronchopulmonary dysplasia. Mucolytics, which are used
to treat thick secretions and facilitate pulmonary
toilet, especially in conditions such as cystic fibrosis. Antibiotics, or
antivirals, can be used to treat respiratory
tract infections as seen in patients
with cystic fibrosis or even immunocompromised
patients. Anesthetics are used to
anesthetize airway reflexes to allow for airway procedures
such as a bronchoscopy. Irritants, such as
hypertonic saline, is used to induce
sputum production for diagnostic purposes. And in some cases,
these medications can be delivered as a controller
for a chronic pulmonary condition as well. Some health care
providers would refrain from performing this procedure
in patients with allergies to the administered
medication or do not have a strong enough
respiration to inhale adequately the medication itself. Equipment. Let’s discuss some
of the equipment and the necessary steps
required to appropriately and safely administer
aerosolized medications to pediatric patients. What I’m going to describe
to you in this segment is how to set up a small
volume jet nebulizer. There are a few
different components that we need to look at
closely before we administer our medication to our patient. First, the interface. We want to make sure that
we have an appropriately sized mask depending
on the patient size. We need to make sure that we
have the nebulizer itself. If you are using a nebulizer
that’s been used previously, make sure to inspect
the inside of it to ensure that no
crystallization from previous treatments
will interfere with the generation of
appropriately sized particles during this application. You also need to have
oxygen tubing connected to a gas source, which
can be either oxygen itself, air, some
mixture, or even Heliox. We’re also going to
need to make sure that we have our appropriately
dosed medication. Demonstration of Nebulizer Use. I’ve double checked
the medication dosage. We looked at the
order from the doctor, and everything looks
appropriate for our child. I’ve gathered the
necessary equipment and I’m going to select
the appropriate interface. Let’s go over a few options. Common interfaces include
various size face masks and mouthpieces. A mouthpiece is preferred
in cooperative children that can readily follow instructions
to ensure that a good seal is maintained between the child
and the nebulizer mouthpiece. These children should be able to
breathe through the mouthpiece to maximize the effectiveness
of the medication delivery. However, if the patient
is too young, or unable to cooperate for
whatever reason, it’s most appropriate
to utilize a face mask. This interface option requires
only a properly fitting face mask and adequate
respiratory effort. Before we proceed,
we’ll also want to ensure that the patient
is in the correct position. I’m going to put
the head of the bed to approximately
30 to 45 degrees. An important performance
note about jet nebulizers, is that they should be oriented
approximately vertically to work effectively. Tilting the device too far,
perhaps 20 to 30 degrees on any angle in any direction,
can cause the medication to move away from the jet
gas port inside the device and render the
treatment ineffective. If you notice a treatment
you are administering is taking a long period of
time, or there doesn’t appear to be an appropriate volume
of aerosol generated, you may want to
check the nebulizer to ensure proper
vertical orientation. Next, I’m going to connect
the nebulizer to our gas source using oxygen tubing. It should be noted that in
order to adequately power jet nebulizers, a specific gas flow
is required for this device. The manufacturer in
this case recommends nine liters per minute. However, it doesn’t necessarily
matter what type of gas. It could be 100% O2,
air, Heliox, etcetera. You’ll need to exercise
good clinical judgment to determine the appropriate
gas for your treatment. Often, patients
receive 100% oxygen if there are no
contraindications. Simply because this
is the most readily available compressed gas
in most institutions. But importantly, make sure
that the gas flow is not running when you connect it. You should wait until
the setup is complete and the device is adequately
affixed to the child before you start the gas flow. This will minimize the
amount of wasted drug and maximize the received dose. Next, I have our drug. I’ve removed the
cap and I’m going to take our medication, which
is in a liquid suspension, and place it inside the device. We are going to replace the
cap, attach the interface, affix the oxygen tubing
to the bottom portion of the nebulizer, and place
the mask on our patient. I’m going to turn
the oxygen flow rate onto nine liters per
minute, as per recommendations by the manufacturer. This treatment should last
anywhere from 10 to 20 minutes. Now that the
treatment is running, let’s discuss inhalation
therapy quality. There are three main
components to quality. One, the appropriate
medication, dosage, and indication for our patient. Two, assurance of
good quality aerosol. And three, maintenance of
good, proper breathing pattern in our subject. Aerosol quality can be assessed
a couple of different ways. First, a visual assessment
of the aerosol density can be done. Here, you note both good
and poor aerosol quality. Second, the time
that is required to complete aerosolization of
a prescribed medication volume should be noted. If the time is much
too short or too long, a problem with delivery
may have occurred. If the time is
excessively short, some medication may
have spilled either by the incorrect
orientation of the nebulizer or a crack in the device. If the time is too
long, on the other hand, be sure to assess
the gas flow rate. Assess the nebulizer for
crystallization in the chamber, and assess for manufacturing
defects of the device. If possible, you should
also encourage your patient to maintain a consistent
and deep breathing pattern during the treatment. Demonstration of
Metered Dose Inhalers. In the next segment,
I’m going to discuss the proper application of
metered dose inhalers, or MDIs, in children. A metered dose inhaler
consists of a canister, which contains a propellant–
a compressed inert gas– and a medication. An actuator that the canister
is inserted into, and when depressed, directs a
specific amount of medication through the mouthpiece. And sometimes a
counter, which retains a record of the
number of canister depressions to help gauge
when a canister should be changed for your subject. It’s important to
note that there are several different masks
and interfaces when using MDIs. In general, it’s good practice
with infant and pediatric subjects to use an
antistatic valved holding chamber or spacer, since
they may have difficulty with the coordination
and control involved in using MDIs independently. A holding chamber, or
spacer as commonly known, is a device that is basically
an aerosolized medication reservoir. It allows a collection
of medication to be held in a chamber,
that can then be inhaled and not lost to the
room during delivery. We have several different
interface options. Depending on the
patient’s size we have different masks and
different sized chambers. Additionally, we
have spacers that are built for endotracheal
and/or tracheostomy tubes. Also, we have inline
MDIs which can be used during mechanical ventilation. I’ve selected a
pediatric size chamber with an appropriate
mask for this patient. Some components of
the chamber itself. The interface; an
appropriate size interface is essential to minimize
leaks during use and optimize delivery of our medication. The one way inhalation
valve separates the chamber from the patient and ensures
that upon inhalation, the patient draws gas
through the chamber that contains the medication. The one way exhalation valve
ensures that upon exhalation, gas is diverted through
a separate channel out to the room and away
from the medication chamber. The exhalation valve
helps to prevent dilution of the medication
from exhaled gases. The antistatic chamber
and the MDI adapter; the MDI adapter is where the
chamber interacts with the MDI and is able to
accept medication. One important thing to
note when using MDIs is to appropriately and
vigorously shake the canister before each actuation. About 30 to 40 seconds
of aggressive shaking between actuations will ensure
that the highest proportion of the prescribed
dose on the canister will be administered
to your patient. Place it back into
the plastic holder. Place it into our chamber,
and let’s actuate a puff here and give it to our patient. Now, it’s not essential
for the patient to synchronize breathing
with the canister actuation since we’re using a
chamber that helps to ensure the medication
is delivered on demand. I’m going to shake for
another 30 to 40 seconds after that actuation before
we give our second dose. I wait four to five
breaths between actuations to make sure that the patient
inhales all the medication in the chamber possible. Cleaning. For aerosol delivery equipment,
including nebulizer and holding chambers, devices should
be cleaned and disinfected appropriately. Although there is
some controversy in the literature as to
the most effective methods of disinfection, the
following recommendations are noted by the nebulizer
manufacturers, the American Association of Respiratory
Care, and the Association for Professionals in Infection
Control and Epidemiology. For a disposable handheld
small volume nebulizer, like the one discussed
earlier in this lecture, should be rinsed
thoroughly after each use and allowed to completely
air dry between treatments. A mask, or mouthpiece, should
be wiped with an alcohol pad. The entire set up should be
discarded every 24 hours. Holding chambers should be
cleaned with a detergent, rinsed, and allowed to dry. Depending on the
specific holding chamber, manufacturer recommendations
may vary slightly as to the frequency of cleaning. Recommendations
for cleaning an MDI include removing the medication
canister from the actuator, and running the actuator under
warm water for one minute, or 30 seconds per end. Importantly, this
procedure does not directly disinfect the device. Rather, it cleans
the point of contact between the actuator
and the canister that can build up
with medication and help to ensure proper
performance and medication delivery. Small volume nebulizers,
holding chambers, and MDI actuators should not
be shared between patients. Complications. The complications
that you may observe include tachycardia, or
dysrhythmias, no improvement in breathing pattern or gas
exchange, oral candidiasis, or pupillary changes
with certain administered medications. I encourage you to monitor
your patient closely for signs and symptoms
of complications, and to be prepared
to manage them. This includes having
the necessary equipment available to treat the
complications should any arise. Assessment and Monitoring. Aside from the assessment of
aerosol medication quality discussed previously,
it’s important to monitor the patient’s vital
signs, including oxygen saturation, respiratory
rate, heart rate, blood pressure, as well as
assess lung sounds before, during, and after administration
of the medication. Following administration
of inhaled medication, you should document the
following information in the patient’s medical record. The indication for the
administered medication, the date and time that the
medication was administered, the child’s response
to the treatment, including his or her vital
signs, and lung assessment before, during, and
after the procedure. As well as any
pertinent information such as observed adverse
reactions, or sputum production. And, of course, document
the specific dosage and type of medication that
was administered. This concludes our
video on administration of inhaled medication. Thank you. Please help us improve the
content by providing us with some feedback.


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