I. Subject: Medication Delivery by Metered Dose Inhaler (MDI)

Transcription

1 I. Subject: Medication Delivery by Metered Dose Inhaler (MDI) II. Policy: Aerosol medication administration by metered dose inhaler will be performed upon a physician's order by Respiratory Therapy personnel. The MDI itself will be requisitioned from the Pharmacy by Nursing Service personnel and delivered to the patient's nursing unit. The inhaler will be labeled with the patient's identification, the medication type, and dosing instructions. The inhaler will be placed in the patient's medication drawer on the nursing unit. Respiratory Therapy personnel will obtain the inhaler prior to each scheduled treatment. In the event that the MDI is ordered for PRN administration, the Respiratory Therapist will check with the patient on a scheduled basis to inquire about the patient's need for administration of the drug. This policy does not apply to nasal inhalers which will be given by Nursing Personnel and will appear in a normal fashion on the MAR. III. Indications: A. Meter Dose Inhaler (MDI) is used to deliver a measured amount of medication to the respiratory tract. NOTE: Indications for the actions of respiratory medications are covered in the Pharmacology section of this manual. IV. Contraindications: The Respiratory Therapist should be aware of the contraindications of aerosol therapy. A. Known hypersensitivity to delivered medications. B. Inability of patient to coordinate medications discharge, breathing maneuver, and 3-5 second breath hold. C. Vital capacity less than 30% of predicated. 1

2 V. Rationale: Inhaled aerosols are used both therapeutically and prophylactically in the treatment of acute and chronic respiratory illness. The purpose of aerosol therapy is to deliver small particles of drugs throughout the respiratory system. It is desirable to achieve sufficient penetration of the system for deposition to occur in the lower airways. The particle size and concentration of the delivered fluid are major determinants in achieving the desired deposition to take place. Proper deposition also depends on the breathing pattern of the patient and the turbulence created during inhalation so that the droplets will be evenly distributed in the tracheobronchial tree. Metered dose inhalers utilize a gas propellent to deliver a known dose of medication in aerosol form. Since coordination of inhalation with aerosol discharge is critical, as spacer (such as an Aerochamber) acts as a small reservoir to optimize dose delivery. Delivery of medications via aerosolization is site specific and reduces systemic side effects. VI. Equipment: The following materials are needed to administer medication utilizing an MDI. -medication canister -actuator (outer plastic shell) -spacer device VII. Procedure: The following is the procedure used with MDI therapy: A. Check physician's order- 1. Order should include the frequency, type and amount (number of breaths) of medication. NOTE: If any of the above in "1" listed are not on the physician's order the physician should be called by the RT or RN for clarification. B. Enter the patient's room, greet, identify and introduce yourself to the patient. 2

3 C. Upon initial start of treatment, state reason for procedure and it's therapeutic objectives. D. Pre-observations of patient- 1. Note pulse and respiratory rate 2. Auscultate for breath sounds 3. Note any abnormalities in ventilatory mechanics and pattern. E. Assemble the necessary equipment- 1. Make sure the canister is firmly and fully inserted into the outer plastic shell or actuator. Press canister firmly into the actuator and rotate back and forth several times without firing the aerosol. Remove the cap from the mouthpiece. Hold the inhaler and shake it well. Attach spacer. 2. Prime MDI prior to first use by dispensing 2 puffs into spacer. F. Administer treatment to patient- 1. Instruct patient to breath out normally and then place mouthpiece over tongue and well into mouth with lips closed tightly around mouthpiece. 2. Have patient press the top of the medication canister firmly between forefinger and thumb and at the same time inhale slowly and maximally through mouth. Have patient hold breath for 3-5 seconds, then exhale normally. 3. Have patient release pressure on canister, remove inhaler from mouth and breath out gently. 4. Have patient wait at least 60 seconds, before a second puff. Then have the patient shake the inhaler and follow steps 1-3. NOTE: The spacer should aid aerosol delivery since timing of aerosol discharge and inhalation is not as critical, however, if inhalation is insufficient, or the patient cannot begin inhalation within 3 seconds of discharge, notify the physician. 3

4 5. For MDI administration in a ventilator circuit, place spacer between inspiratory limb and patient wye with the cannister end distal to the patient. Shake MDI canister, open cap on spacer canister part and insert nozzle of MDI canister. Recommended technique and ventilator settings for MDI aerosol delivery: a) Vt greater than 500 ml (in adult patients) b) Inspiratory time Greater than 0.3 of total breath duration c) Ensure that ventilator breath is synchronized with patient's inspiration d) Shake MDI vigorously e) Place canister in actuator of a cylindtrical spacer situated in the inspiratory limb of circuit f) Actuate MDI to synchronize with precise onset of inspiration by the ventilator g) Allow a breath hold at end-inspiration for 3-5 seconds (as tolerated), or use lower flow rates h) Allow passive exhalation i) Repeat actuation after seconds until dose is delivered j) Return ventilator to previous settings Remove MDI canister and spacer, or collapse the spacer device and leave inline (Aerovent). 6. For MDI administration to a spontaneously breathing intubated patient, insert the inspiratory side of a non-rebreathing T-piece into dispenser end of an ACE device. Attach patient opening of the T-piece to patient's endotracheal airway. Shake MDI cannister, open cap on spacer cannister port and insert nozzle of MDI canister. Observe patient and at end expiration, actuate canister. Instruct patient to inhale slowly and deeply and hold breath for 3-5 seconds at TLC before exhaling. Remove MDI canister, spacer, and non-rebreathing T-piece. 7. For MDI adminstration to an intubated patient with resuscitation bag, connect the cannister end of the spacer to the resuscitation bag. Connect the other end to the ET tube with a 15 mm adaptor. Do not use an elbow. Shake MDI canister, open cap on spacer to patient's endotracheal tube, and at 4

5 end-expiration, actuate canister. Use the resuscitation bag to deliver deep breath to patient. Remove MDI canister and spacer. 8. Attachment of a mask to the spacer may aid in aerosol delivery to certain patient groups, such as pediatric patients. The patient must, however, have an opened mouth, inhaled deeply for adequate medication delivery. G. Post observations of patient- 1. Note pulse and respiratory rate. 2. Auscultate for breath sounds. 3. Note any abnormalities in ventilatory mechanics and pattern. 4. Any improvement in patient's breathing pattern. H. Clean equipment and store spacer in patient's room. Store MDI canister in patient's medication drawer on the nursing unit. VIII. Special Considerations: A. Corticosteroid MDI should be administered after bronchodilator. Have patient hyperextend neck during inhalation. Patient should rinse mouth and throat after dosing. B. Dry powder inhalers require rapid inspiration with high flow rates ( L/min) for dispersion. C. Additional puffs of medication are generally required for intubated patients due to the loss from ET tube, connections and humidity. D. Check for proper dispensing of medication and clean nozzles as required. IX. Documentation: Documentation of the MDI treatments should include the date, time, duration of the treatment, pre and post respiratory and pulse rates, type and dosage of medication (if ordered), auscultation of patient's breath sounds, FIO2, toleration of treatment, 5

6 documentation of productive or non-productive cough along with description and amount of secretions. Upon initiation of the first treatment, the patient's understanding of the procedure and its therapeutic objectives should be documented. Note any adverse reactions or abnormalities as they occur with proper corrective measures taken. X. Hazards: Complications that could be associated with a aerosol treatment are: COMPLICATIONS Adverse drug reaction to deliver medications Increase greater than 20% over pre/pulse rate Bronchospasm Fungal infections in mouth and oropharynx PRECAUTIONS/REMEDY: Stop therapy and notify physician and RN. Stop therapy and notify physician and RN. If this happens to a patient with known reactive airway disease with no bronchodilator, contact physician to add bronchodilator. If bronchodilator administered and bronchospasm occurs, stop therapy and notify the physician and RN. Have patient rinse mouth and throat after inhaling corticosteroids. Notify physician if symptoms observed. 6

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