Bronchodilator Delivery and Nebuliser Trials in Adults
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1 Bronchodilator Delivery and Nebuliser Trials in Adults Acute Management Favour the use of MDI (+/- Spacer) If considering nebuliser Short term treatment Approx. < 3 weeks See optimisation of inhaled bronchodilators below Chronic Management Favour the use of MDI (+/- Spacer) Optimise other treatments long acting bronchodilators, inhaled steroids, pulmonary rehab etc consider DAIRS referral If considering nebuliser If in Acute Hospital/ supported discharge Secondary care is responsible for the short term loan and prescribing If in community to prevent an admission... Specialist nurse and matrons can request emergency loan from equipment service. The prescriber will be responsible for all aspects of its use Reassessment of need If ongoing need for nebuliser, see chronic management See assessment process for long term nebuliser use below Long Term Loan To be assessed by Practice nurse, community matron or secondary care specialist nurse GP prescribes medications Matron/Respiratory Nurse prescribes nebuliser and consumables from Community Equipment and checks its correct use and set up. Community Equipment Service responsibility for upkeep, servicing and emergency repairs. Assess response to trial after 2 weeks Prescriber is responsible for ensuring correct advice, guidance and regular review (including polypharmacy)
2 Reasons to consider long term nebuliser therapy For most patients, metered dose inhalers (used with or without spacers), used with the correct inhaler technique, are sufficient to treat COPD Asthmatics should only have long term nebuliser use after review by secondary care and generally only if at stage 5 of asthma BTS guideline in order to avoid overreliance on nebulised bronchodilators when acutely unwell and to ensure concordance with inhaled corticosteroids. Handheld inhalers with spacer devices can be as effective as nebulisers in acute asthma or COPD. The potential indications to use a nebuliser are: Delivery of high dose short acting bronchodilators (SABA) in COPD Delivery of SABAs to patients who cannot use metered dose inhaler (MDI) (eg hand arthritis, cognitive impairment) Delivery of nebulised antibiotics in bronchiectasis Delivery of mucolytic agents eg hypertonic saline in bronchiectasis Delivery of high dose inhaled steroids in asthma Delivery of SABAs to asthmatic patients with severe disease under supervision of secondary care Optimisation of inhaled bronchodilators and other therapies This should happen prior to initiation of nebulised therapy. Ensure the diagnosis (COPD/ asthma) is secure Patients should be taught and assessed in correct inhaler technique by trained staff with issues of concordance being addressed Regular reassessment and reinforcement of inhaler technique is needed Alternative devices for delivery of bronchodilators should be tried - a Haleraid TM may be useful in patients with poor hand function Where appropriate, other therapies - long acting bronchodilators, inhaled corticosteroids, pulmonary rehabilitation etc - should be favoured over nebuliser use - consider a referral to DAIRS for advice Spacers o Are nearly always required by elderly patients o should be compatible with the MDI o should be cleaned monthly with water and detergent and allowed to air dry o can be used in single actuations followed by inhalation or with tidal breathing o can be used by a carer, usually with a large volume spacer Delivering nebulised bronchodilators There is little agreement about what constitutes a positive response to inhaled bronchodilator treatment, though symptomatic improvement is more important than any measured change in lung function (PEF or FEV1). Options for assessing response include reduction in symptoms, increased ability to undertake ADLs, increase in exercise capacity and/ or improvement in lung function Use of a nebuliser requires some cognitive skill and dexterity so these will need to be assessed in the patient/carer The driving gas for the nebulised therapy should be air unless otherwise specified on the prescription. If a patient is hypercapnic the nebuliser should be driven by compressed air, not oxygen (to avoid worsening hypercapnoea). If oxygen therapy is required it should be administered simultaneously by nasal cannulae at a controlled rate.
3 NEBULISER TRIAL BASELINE ASSESSMENT For use by clinicians in primary, community, integrated or secondary care Patient details: Name: DoB: Age: yrs Consultant / GP: ASSESSMENT DATE: COMPLETED BY: Hospital No: NHS No: Height: m Weight: kg Review current medication Inhalers Technique GOOD/ POOR Corrected Concordance GOOD/POOR Other therapies reviewed Long acting bronchodilators Inhaled steroids Other therapies Baseline spirometry FEV1 FVC Baseline COPD Assessment Test For asthmatics only - PEF diary BD 30 mins after bronchodilator medication throughout trial if change in treatment occurs, reassess the baseline in 1 month if nebuliser therapy is still a reasonable option, commence nebulised bronchodilators QDS Teach use and care of air compressor and nebuliser set Review at 2 weeks
4 NEBULISER TRIAL post treatment review Review: (Date). (Practitioner) Repeat spirometry FEV1 FVC Repeat COPD Assessment Test Jones Health Status Check For asthmatics only review PEF diary Outcome of trial nebuliser YES/NO Review at 6 months
5 Jones Health Status Check Give an example 1 Has your treatment made a difference to you? 2 Is your breathing easier in any way? 3 4 Can you do some things now that you couldn't do at all before, or do the same things, but faster? Can you do the same things as before but are now less breathless when you do them? 5 Has your sleep improved? Produced By Respiratory Group October 2015 Reviewed Dorset Medicines Advisory Group November 2015 Approved By Dorset Medicines Advisory Group November 2015 Review Date November 2017 or before in the light of new evidence and/or recommendations
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