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.
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