Hypertonic Saline (7%) Administration Guideline (adults)

Transcription

1 Hypertonic Saline (7%) Administration Guideline (adults) Full Title of Guideline: Author (include and role): Hypertonic Saline (7%) Administration Guideline for Practice (Adults) Clair Martin, Senior Physiotherapist, Eleanor Douglas, Lecturer/Practitioner Physiotherapist, Fiona Haynes, CF Clinical Specialist Physiotherapist, Division & Speciality: Version: 2 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Clinical Support, Physiotherapy Senior Physiotherapists at NUH Trust wide physiotherapists September, 2021 Patients who are having difficulty clearing pulmonary secretions due to viscous secretions e.g. cystic fibrosis and bronchiectasis and patients with dehydration of the upper airway e.g. post operative patients and those were their upper airway has been bypassed e.g. those with a tracheostomy or endotracheal tube. It excludes patients in acute bronchospasm and those with hyper-responsive airways. Review of research, minor changes to wording, grammar and spelling errors corrected. Review of randomised controlled trial. Expert committee Summary of evidence base this reports or opinions and / or clinical experiences of respected guideline has been created from: authorities. Recommended best practise based on the clinical experience of the guideline developer This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. Page 1 of 6

2 Hypertonic Saline (7%) Nebuliser Guideline For Practice 2018 (Adults) Version: Version 2 Review Date: September 2021 Contact: Clair Martin, Senior Physiotherapist, Fiona Haynes, Cystic Fibrosis Clinical Specialist Physiotherapist or Eleanor Douglas, Lecturer/Practitioner Physiotherapist Ext: Disclaimer This guideline has been registered with the Nottingham University Hospitals Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in any doubt regarding this procedure, contact a senior colleague. Caution is advised when using guidelines after the review date. Please contact the named above with any comments / feedback. Introduction/Indications For Use This procedure describes the nebuliser administration of hypertonic saline (7%) in aerosol form and maybe indicated in circumstances were patients have difficulty clearing secretions despite chest physiotherapy, adequate systemic hydration, isotonic saline (0.9%) nebulisation and/or mucolytics. It may also be indicated in patients whose upper airway is bypassed (via endotracheal or tracheostomy tube) and in patients who are nil by mouth. Mechanisms of action The primary mode of action is through induced coughing. Hypertonic saline breaks the ionic bonds within the mucus gel, which could reduce the degree of cross linking and entanglements and lower viscosity and elasticity (Ziment, 1978) Hypertonic saline induces an osmotic flow of water into the mucus layer, rehydrating secretions and thereby improving mucus rheology (Robinson et al, 1997) Hypertonic saline increases the airway surface layer (ASL) volume of the mucus, which in turn results in increased mucociliary clearance Administration may or may not be accompanied by oxygen administration. In the circumstance of the patient requiring oxygen the nebuliser should be driven by 6 litres oxygen/minute. Note: In patients with a known hypoxic respiratory drive the nebuliser should be driven by an air compressor and the patients oxygen can remain in situ via nasal cannula (1-4 litres of oxygen). Contraindications/Precautions Bronchospasm History of airway hyper-responsiveness Complications Wheezing or bronchospasm Infection Pharyngitis Sinusitis Haemoptysis Patient discomfort Reduction in FEV 1 and oxygen saturations initially, however tolerance improves with repeated doses Limitations The efficacy of intermittent use of saline nebulisers as a means of reducing mucus has not been established. Saline nebulisers are not a substitute for systemic hydration. The physical properties of mucus are only minimally affected by the addition of water aerosol. Page 2 of 6

3 Procedure Action Request the prescription of 4mls of 7% (hypertonic) saline for nebulisation from a qualified prescriber. This must be prescribed on the PRN section of the drug chart. Nebulisers can be prescribed twice a day, or a maximum of 4 times in 24 hours A bronchodilator (e.g. Salbutamol) should also be prescribed this can be delivered by inhaler route or nebuliser. This can be prescribed on either regular or PRN section of the drug chart. Auscultate the patient s chest Check the Bronchodilator (if to be given by nebulised route), amount and expiry date with another qualified member of staff e.g. nurse or physiotherapist and administer prior to the hypertonic saline nebulisation. If by inhaler route than ask the patient to self-administer as prescribed. Sign that the salbutamol nebuliser/inhaler has been administered on the patients drug chart. Check the hypertonic saline (7%), amount (4mls) and expiry date with another qualified member of staff e.g. nurse or physiotherapist The first dose should be administered by a qualified physiotherapist. Sign the drug chart to document the administration of the hypertonic saline Assist the patient into a comfortable position, Preferably sitting upright and advise to take normal steady breaths (tidal volume) Explain to the patient the effects of the nebuliser and that coughing may be induced. Explain it has a salty taste Wash hands and place the hypertonic saline into the nebuliser chamber Connect one end of the nebuliser tubing to the air compressor (if oxygen administration is not required) or oxygen flow meter (the flow rate should be set at 6 litres/min) and the other end to the nebuliser chamber Select mouthpiece preferably or a face mask (if the patient cannot tolerate a mouthpiece) and connect to the nebuliser chamber Page 3 of 6 Rationale Drugs are given as prescribed Salbutamol should be prescribed if tolerated by the patient. Atrovent should be avoided if possible as it can increase mouth dryness and the viscosity of sputum Bronchospasm is a precaution to giving hypertonic saline and should be excluded prior to administration Bronchospam is a frequently reported side effect of hypertonic saline nebulisation. A bronchodilator should be routinely administered prior to hypertonic saline nebulisation Drug is given as prescribed and avoids administration errors Ensures the patient is monitored for any side effects that may occur on the introduction of hypertonic saline nebulisers To minimise dyspnoea and to allow maximum lung expansion in order to ensure optimal deposition of the hypertonic saline To educate the patient To reduce the risks of cross infection To enable the drug to be nebulised correctly Using a mouthpiece will allow more of the drug to be inhaled. Using a facemask allows the drug to escape around the mask and through the mask holes and can cause eye irritation Note: In patients with a known hypoxic respiratory drive the nebuliser should be driven by an air compressor and the patients oxygen can remain in situ via nasal cannula (1-4 litres of oxygen)

4 As indicated by the physiotherapist encourage the patient to complete thoracic expansion exercises (see ACBT guideline 2018) Observe the patient during the procedure for any change in condition, for example: bronchospasm, increased respiratory rate, drop in oxygen saturation & intolerance If change in condition then seek appropriate treatment. To encourage secretion clearance. To monitor the patient in case of any adverse effects. If bronchospasm is present then stop the hypertonic saline nebuliser and administer a bronchodilator via nebuliser or inhaler route (depending on prescription) If increase in respiratory rate then stop hypertonic saline nebuliser If drop in saturation then stop hypertonic saline nebuliser and titrate oxygen accordingly to maintain safe Sp02 level. Occasionally tap the nebuliser chamber during nebulisation. The patient can be encouraged to do this if able Liaise with medical staff and document adverse response in medical notes. This shakes down the large droplets into the chamber and ensures maximum delivery of the hypertonic saline Keep nebuliser chamber upright This allows maximum amount of saline to be delivered effectively Nebulisation should be complete after 5-10 minutes. There will always be a small amount of fluid left in the chamber. Switch off the compressor or flow meter After each use discard the remaining hypertonic saline and clean the chamber as follows: Clean and rinse the nebuliser chamber with sterile water. Tap water should not be used Ensure the chamber is thoroughly dried in air Chambers should be used for a 24hour cycle and then be disposed of Mouthpieces and masks should be cleaned regularly All equipment should be replaced when soiled The nebuliser unit should be covered and stored Page 4 of 6 Nebulisers cannot be run to dryness To reduce the risk of bacterial colonisation of the equipment Organisms may multiply in any fluid left in the equipment and may then be inhaled by the patient Paper towels should not be used to dry nebuliser components as small particles may block the nebuliser and compromise airflow To reduce the risk of bacterial contamination being aerosolised To reduce the risk of the chamber becoming blocked Crystallisation of the nebuliser pot may occur if saline solution is allowed to dry or evaporate and this may effect the effectiveness of the nebuliser To keep clean and dust free

5 The compressor should be wiped clean after use Subsequent doses of hypertonic saline can be administered by a qualified physiotherapist a part of a physiotherapy treatment session or by nursing staff if nebulisation is required more frequently to assist secretion clearance. Note some patients with chronic lung conditions e.g. Cystic Fibrosis may self-administer hypertonic saline Hypertonic Saline can also be diluted for example mixing 2mls 7% and 2 mls H 20 to give 3.5% and gradually build up to 7%. This may be indicated if the patient has a history of airway hyper-responsiveness. If they remain on diluted, then Mucoclear 3% is available from GP s. Care of equipment Compressor Wipe with a damp cloth when the unit is unplugged and store it in an appropriate place, the compressor should not be stored on the floor or near water hazards. Compressors must be serviced annually by MESU. Nebuliser pots/masks Eliminating sticky fluids from the nebuliser and condensation from the tube allow the nebuliser system to produce the quality and output as required. Adequate washing of the pot and mask after each treatment is therefore an important part of the cleaning procedure. Equipment should be replaced when soiled. References AARC Clinical Practice Guideline. Bland Aerosol Administration 2003 Revision and Update. Respiratory Care 48: Adult Nebuliser Guidelines. Nursing Practice Guidelines. Nottingham City Hospital/Queens Medical Centre/ Rushcliffe PCT Lannefors L,Heslop C, Tierlink, C (2000) Nebuliser Systems. European Respiratory Society Nebuliser Guidelines: Clinical Aspects 76: 572 Robinson M, et al (1997) Effect of increasing doses of hypertonic saline on mucociliary clearance in patients with cystic fibrosis. Thorax 52, (10):900 3 Ziment, I (1978) Respiratory pharmacology and therapeutics. Philadelphia: WB Saunders Page 5 of 6

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