NEBULIZERS, METERED DOSE INHALERS, AND DRY POWDER INHALERS Douglas S. Gardenhire, Ed.D, RRT-NPS MODULE 1 Manipulate Small Volume Nebulizers by Order or Protocol 1
Objectives for Module 1 At the end of this module the student should be able to: Gather necessary equipment to deliver a small volume nebulizer treatment to a patient. Assemble small volume nebulizer and determine proper function. Assess function and troubleshoot small volume nebulizer as needed. Small Volume Nebulizer (SVN) Gather Equipment Typically disposable Pneumatically powered Oxygen Compressed air 4-8 LPM allows a treatment time of approximately 10 minutes depending on volume Typically delivers liquid medication of 3-5 ml Particle Size Choose a nebulizer that matches the therapeutic need for the patient Risks to practitioners SVNs usually allow nebulized liquid to escape into the atmosphere Transmittable diseases may also be allowed into the atmosphere Protect yourself by using universal precautions A SVN with one-way valves and filters can be used (i.e. Respirgard II) 2
Small Volume Nebulizer (SVN) Assemble SVN Consists of Medication cup or reservoir Manifold The manifold and medication cup may need to be screwed together Mouthpiece A mask may be substituted if necessary Reservoir or extension tube Depending on packaging this may be optional Small bore oxygen tubing Used to connect to flowmeter, adjust to manufacturer s directions (4-8/LPM) Check for leaks and nebulization of liquid Small Volume Nebulizers (SVN) Troubleshoot SVN If the SVN fails to create aerosol, check the following Is it assembled correctly? Check all fittings and make sure the manifold and medication cup are screwed together tightly Is the small bore tubing connected to the SVN and power source? Connect correctly and tightly If improper function is found after troubleshooting Change to a new nebulizer Consider changing to a different device MDI DPI 3
MODULE 2 Manipulate Metered Dose Inhaler by Order or Protocol Objectives for Module 2 At the end of this module the student should be able to: Gather necessary equipment to deliver a metered dose inhaler to a patient. Assemble metered dose inhaler and determine proper function. Assess function and troubleshoot metered dose inhaler as needed. 4
Metered Dose Inhaler (MDI) Gather Equipment Dispenses predetermined amount of medication Available in single and combination medications Simple operation Medication mixed with a propellant Depress canister to actuate a dose with the actuator Make sure that the canister and actuator are aligned Shake the canister Hold upright Priming the canister may be needed Metered Dose Inhaler (MDI) Assemble and check function Place canister into actuator Shake the canister Hold upright Depress canister to actuate a dose with the actuator Make sure that the canister and actuator are aligned Priming the canister may be needed Clean as needed 5
Metered Dose Inhaler (MDI) Troubleshoot Check proper placement of canister and actuator Determine medication is present If patient cannot properly use device, consider a spacer or breath-actuated MDI If use of a spacer device is unsuccessful, consider changing to SVN or DPI MODULE 3 Manipulate Dry Powder Inhaler by Order or Protocol 6
Objectives for Module 3 At the end of this module the student should be able to: Gather necessary equipment to deliver a dry powder inhaler to a patient. Assemble dry powder inhaler and determine proper function. Assess function and troubleshoot dry powder inhaler as needed. Dry Powder Inhaler (DPI) Gather Equipment Deliver medication via a dry powder into the lungs Can provide various classes of medication Single dose Spiriva (tiotropium) HandiHaler Foradil (formoterol) Aerolizer Multi-dose Pulmicort (budesonide) Flexhaler Serevent (salmeterol) Diskus Relenza (zanamivir) Diskhaler 7
Dry Powder Inhaler (DPI) Assemble and check function Single dose Open device Place medication in space provided in device Pierce or crush the capsule in the device Remove capsule before next dose Instruction and education is key for patients taking DPIs at home Multi-dose Since several different types of devices exist, check package insert for correct use A counter is included so continued monitoring will show when a new inhaler is needed Dry Powder Inhaler (DPI) Troubleshoot Proper education and practice by the patient is required for the unit to work effectively If a DPI unit fails a new unit is needed Keep DPIs out of high humidity areas as moisture and water can have an effect on how they perform A patient must be able to generate a flow of at least 40-60 LPM Older patients and those under 5 may not be able to generate flows needed Patients using a single dose device should be instructed not to swallow capsule; it must be inhaled to work properly An alternate device such as a MDI or SVN may be needed 8
Example Question An 18 month-old child is seen in the emergency department of a local hospital, and croup is diagnosed. The physician orders a dose of racemic epinephrine via a small volume nebulizer to help reduce the subglottic swelling. What size aerosol particle is most likely to deposit in this region, providing the greatest therapeutic benefit to the patient? A Particles less than 10 µm B Particles 5 to 10 µm C Particles 2 to 5 µm D Particles 0.8 to 1.0 µm Answer: B The upper airway (nose and mouth) is efficient in filtering particulate matter, so generally there is 100% deposition in the nose and mouth of particles larger than 10 µm and 15 µm. Particle sizes 5 to 10 µm tend to deposit out in the upper airways and the early airway generations, whereas particles 1 to 5 µm have a greater probability of reaching the lower respiratory tract from the trachea to the lung periphery. Larger or coarser aerosol particles (>5 µm) may be useful for treating the upper airway (nasopharynx and oropharynx). 9
Example Question You are treating a patient who has a confirmed diagnosis of Pneumocystis pneumonia. Which type of delivery device should you choose to administer the dose of pentamidine ordered by the physician? A Respirgard II B MDI C Pari LC D DPI Answer: A Respirgard II is the only approved device to administer pentamidine. 10
Example Question A patient carries an albuterol metered dose inhaler (MDI), which she claims to use every few weeks. She complains that the first dose actuated from the device seems to have no effect on her bronchospasm. What suggestion would you make to correct the problem? A Discharge a waste dose before using the MDI B Replace the device C Administer three actuations instead of the two that her physician prescribed D Recommend use of a small volume nebulizer Answer: A Findings suggest discharging a waste dose if 4 hours have elapsed since the last use of an albuterol MDI (or if the device is stored in the valve-down position). The patient has not suggested that the device does not function, only that the initial dose seems to have no effect on her bronchospasm. A new device would likely produce the same result. Although the initial dose may have little or no effect, the practitioner should never change a patient s prescribed dosage without first consulting the physician (unless following a physician-prescribed protocol). A small volume nebulizer is not nearly as portable as an MDI and may cause compliance issues with the patient. Proper instruction would allow the MDI to be used with greater effectiveness. 11
References Gardenhire, D.S. Rau s Respiratory Care Pharmacology, ed. 8, St. Louis, 2012, Elsevier. 12