every breath for you Nebula A Refresher for Nurses
PREAMBLE When you're a nurse you know that every day you will touch a life or a life will touch you It is this truth that makes your role as vital as the treating physician, in gifting a better quality of life to a patient, particularly when it comes to those who struggle to breathe every time. Cipla has always been in the forefront to support healthcare in India and towards providing the best care for those struggling to breathe, we are all the more committed. In this regard, we realize your role as vital and hence have designed an update called NEBULA - A Refresher for Nurses on Airways Disease Management. This booklet captures the essential information on Airways Diseases which will help you in your day to day interface with patients.
WHAT IS ASTHMA? Asthma is a chronic inflammatory disease characterized by airway hyper-responsiveness to a variety of stimuli resulting in bronchospasm which reverses, spontaneously or with treatment. Many people suffer due to asthma across all age groups. Asthma often begins in childhood. Many of the asthmatics are children of age group below 5 years. WHAT IS ABC OF ASTHMA? A= Airway hyperresponsiveness B= Bronchoconstriction C= Chronic inflammation.
Normal airway: The lumen is wide without any swelling or constriction. Asthmatic airway: Muscles around the airway are tightened up resulting in or narrowing the airway lining called as- BRONCHOSPASM, while swelling & redness in airway lining is termed as INFLAMMATION. Along with Nebula A Refresher for Nurses
Triggers Triggers are things that when inhaled can start asthma. They can vary from person to person. Recognition of triggers and avoiding them is the first step towards controlling asthma.
What are the symptoms of asthma? Cough Wheezing Breathlessness or Dysponea Chest Tightness Asthma is on rise. This may be because of various reasons like increasing pollution, industrialization, changes in lifestyle, eating habits, junk food. Asthma a presentation Acute exacerbation Chronic asthma Mild Modearate Severe Life threatening Mild intermitted Mild persistent Moderate persistent Severe persistent Nebula A Refresher for Nurses
What is acute exacerbation of asthma? It is also known as asthma attack or acute asthma. It is an episode of progressive increase in shortness of breath, cough, wheezing, or chest tightness, or some combination of these symptoms. All patients with asthma irrespective of their severity; are at a risk of developing an acute attack Along with symptoms acute asthma can also be identified by some signs like: Inability to complete a sentence Tachycardia [rapid heart beats] Tachypnea [rapid breathing] Accessory respiratory muscle use [around neck] Excessive sweating Cyanosis [blue discoloration of skin, lips in acute severe cases]
How to manage acute asthma? Acute asthma management requires high doses of drugs which will help to open the airways, i.e. bronchodilators like Asthalin, Levolin, Ipravent or Duolin. The rise in inflammation also needs to be taken care of; hence anti-inflammatory drugs are also given like Flohale, Budecort or Budesal. All these drugs needs to given at high doses, which can be conveniently given via a NEBULIZER. Nebula A Refresher for Nurses
COPD Chronic Obstructive Pulmonary Disease. Chronic -means long-term i.e. will not go away. Obstructive - means the airways are partly blocked Pulmonary - means related to the lungs Disease - means illness What causes COPD? COPD is commonly linked to cigarette smoking. Smoking has already been associated with lung cancer and heart diseases but it also leads to COPD. Other risk factors are: 1. Occupational exposures to smoke 2. Exposure to indoor pollution like chulla smoke 3. Exposure to outdoor pollution like exhausts from vehicles
Causes of COPD Smoking Pollution Chullah smoke Occupational exposure Nebula A Refresher for Nurses
What are the symptoms of COPD? Continuous and productive cough Exertional dyspnoea Continuous and progressive breathlessness What is the difference between asthma & COPD? FACTOR Young age at onset Sudden onset of disease Smoking history Allergy Dyspnoea Wheezing Coughing Sputum Production Asthma Often Often Sometimes Often Often Often Sometimes Seldom What is acute exacerbation of COPD? Present in COPD Almost never Almost never Almost always Sometimes Often Sometimes Often Often It is an event in the natural course of the disease characterized by a change in the patient`s day to day breathlessness, cough and/or sputum; and it is often acute in onset. This may require change in regular medication.
How to manage acute COPD? Acute COPD management requires high doses of drugs which will help to open the airways, i.e. bronchodilators like Asthalin, Levolin, Ipravent or Duolin. All these drugs needs to given at high doses, which can be conveniently given via a NEBULIZER. Nebula A Refresher for Nurses
Nebulization What is a NEBULIZER? It is a device that converts liquid drug into a fine mist or aerosol which can be inhaled into the lungs within a short period, 5-10 mins. It is the form of inhaler treatment used for acute asthma & COPD. Why nebulization? Immediate relief is required which can be achieved only from inhalation therapy. Patient is critical hence unable to co-ordinate with inhaled devices like inhaler and Rotahaler. Nebulization is the best resort to give optimal dose and targeted drug delivery.
What are the advantages of nebulizer over injectables and orals? Over Injectables Targeted drug delivery Lesser side effects Non invasive / Painless Easy to use Over Orals Targeted drug delivery Lesser side effects Faster onset of action Very useful in acute cases Where nebulizers are used? Acute attacks of asthma and COPD ICUs Ward, post operative At home, when the patient can t use other inhaler devices. Infants, children and elderly patients who can t use other inhaler devices. Nebula A Refresher for Nurses
What are the types of nebulizers? Jet nebulizer: Based on compressed air technology Widely used Economical Any form of liquid can be nebulized Ultrasonic nebulizer: Based on high frequency sound waves technology Finest mist and better deposition Not preferable for suspensions Reduced sound Costly, thus limits its use
What are the parts of nebulizer? Compressor Tubing Nebulization chamber Mask/Mouthpiece Compressor The compressor is the portable pump which provides power for nebulizer. Keep the pump covered when not in use Wipe over with a damp cloth if it gets dusty If a filter is fitted it will need replacing or cleaning depending on the manufacturers instructions Nebula A Refresher for Nurses
Tubing This does not require washing If some condensation in the tubing is noticed, take off the nebulization chamber, turn on the air pump and blow out the condensation by shaking the tubing Replace the tubing if any dirt is seen in it, or cracks appear Nebulization Chamber The nebulizer is the small chamber into which the liquid medicine is put and through which the air is blown to make a mist. This needs to be rinsed in warm water after every use. This is because the medicine comes in a salt solution and some may get left in the bowl. This can crystallize and block up the outlets. After rinsing the chamber, connect up tubing to it, switch on pump, blow air through for a few seconds. Do not wipe out! Ideally the chamber also needs to sterilised weekly if it is used regularly. Soak for half an hour in
half water and half vinegar. Rinse well then blow through with the air pump on for a few seconds. Don't wipe out! Nebulizer chamber needs replacing when they start to leak. If the chamber is taking longer than normal to nebulize the drug solution, it may be that there is a need of a new chamber. Face mask and Mouthpiece These should be sterilised in the same way as the chamber, at least twice a week. They should be replaced incase of crack, or the face mask doesn't fit properly. Nebula A Refresher for Nurses
How to use Nebulizers?
Neb la u A Refresher for Nurses
Neb la u A Refresher for Nurses
Important aspects to remember: Fill Volumes Ideal volume to be put in the nebulization chamber is usually 2-4 ml. Nebulization Time Time from starting nebulization until continuous nebulization has ceased. For bronchodilators it should be <10 mins. Nebulization End point Patients should be nebulized for about a minute after 'spluttering' sound occurs. Residual volume of 0.5 to 1 ml will always remain in the nebulizer. Driving gas flow rate Most jet nebulizers work at a flow rate of 6-8 l/min. Oxygen can be used if a compressor is not available.
Breathing pattern of patient Steady normal breathing Occasional deep breath Prefer the facemask when patient is Too critical Unconscious Pediatric Prefer mouthpiece when patient is Comfortable enough to hold the mouthpiece Receiving anticholinergics Receiving steroids Neb la u A Refresher for Nurses
Respirator Solution Contains the drug to be nebulized. Before use it is important to d i l u t e this drug in normal saline in ratio of 1:3 Care should be taken that a f t e r dilution total volume in the chamber should not exceed 4 ml. Respules Respule is an ampoule containing liquid drug to be nebulized. It contains drug which is pre diluted and hence can be used directly. Respule should be twisted and liquid should be directly poured into the nebulization chamber. For better response and to avoid inconvenience respules should be preferred.
Cleaning: After the use of nebulizer, clean it according to instructions. Neglecting to do so will promote bacteria growth in liquid remained in chamber. Store nebulizer and accessories in a clean, dry, and dust-free location. Dispose off nebulizer tubing that becomes cloudy or retains moisture very often. Replace disposable parts, tubing, and filters according to manufacturer s instructions. Using a nebulizer cup longer than indicated will result in slower, less efficient delivery of medication. When using a nebulizer, always use a mask or mouthpiece when giving or taking a treatment. Simply aiming the mist at a baby s face does not ensure that any medication reaches small, swollen airways. If treating infants and toddlers, purchase supplies that can be used when the child is in a reclined position or sleeping. Nebula A Refresher for Nurses
Keep nebulizer batteries charged or have replacement batteries handy. Only use medications made specifically for nebulizers. Precaution to avoid infection Since the aerosol from the nebulizer goes directly inside the lungs, there is a chance if aerosol is contamineted, consequently lungs can be infected. Following are the precautions that ought to be observed. Wash hands thoroughly before opening the cup of the nebulizer. Respules should be carefully opened and contents poured into a thoroughly clean and dry nebulization chamber.
Things to remember: Do s Nebulizer's parts should be checked regularly. Separate masks should be used for adults and children Disinfection of mask should be done after each use. Patient should be instructed to sit upright and breathe normally (normal steady breaths). Combination should be preferred over mixing two drugs. Hygiene should be maintained. Nebulization has to be done by a trained person. Respules should be preferred over respirator solution Mouth should be rinsed after nebulizing steroids to avoid oral thrush. Nebulizer should be kept upright. Nebula A Refresher for Nurses
Don ts Cracked & jammed chambers and tubes should not be used. Level of liquid in chamber should not exceed 4.5 ml. Patient should be instructed not to talk during nebulization. Drug should not reach the eyes. Can cause other complications. Spluttering sound indicates drying up of the drug i.e. end point of nebulization. Not to talk during the nebulization. To prevent attacks in future, asthmatic patients are recommended to take regular anti-inflammatory drugs as maintenance therapy with MDI or DPI.
Cipla Respules: A Quality Apart We manufacture 91 million respules per year We make each one like there is only one The state-of-art manufacturing facility Nebula A Refresher for Nurses
Anti-Static walls Prevent any dust & microbes & hence maintain the environment pure & sterile
FFS Pack (Form Fill & Seal pack) Recognized as Advanced Aseptic process by USP# & PDA* Completely automated technology with very limited human intervention Dramatic reduction in potential of contamination Ensures very high degree of sterility # United States Pharmacopeia * Parenteral Drug association Nebula A Refresher for Nurses
Pinhole inspector Individual respule is checked for pinhole of 0.2 microns size Ensures leak-proof packaging
Volume weight checker High degree of assurance for accurate volume in each respule Nebula A Refresher for Nurses
Twist and squeeze mechanism Offers ease to patient/user to remove the liquid Tamper-proof seal for the respule
Light protected pouch Protects the product from light Offers a tamper evident seal
WORLD S WIDEST RANGE OF RESPULES AND RESPIRATOR SOLUTIONS Nebula A Refresher for Nurses
NOTES
NOTES Nebula A Refresher for Nurses
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