Aerosol medication treatments bb 11.10


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  • Aerosol medication treatments bb 11.10

    1. 1. Aerosol Medication Treatments
    2. 2. Three Primary Indications for Aerosol <ul><li>Deliver medication </li></ul><ul><li>Deliver bland aerosols </li></ul><ul><li>Deliver aerosol to induce sputum </li></ul>
    3. 3. Three general reasons for giving aerosol treatments: <ul><li>I. To deliver meds SVN , MDI, DPI, SVUSN, Continuous Neb : </li></ul><ul><li> to lower airways ( MMAD of 2 -5 microns ) - such as bronchodilators, anticholinergics, anti asthmatics </li></ul><ul><li>* allows rapid onset of med </li></ul><ul><li>*less toxic and fewer side effects than if given PO or IV </li></ul><ul><li>to deliver meds to the lung parenchyma - (MMAD of 1 -3 microns ) - such as antibiotics, antifungals ) </li></ul><ul><li>to deliver meds to upper airways – (MMAD of > or=5 microns) - such as racemic epinephrine for upper airway edema </li></ul><ul><li>* several factors determine overall deposition location </li></ul><ul><li>size of particle - breathing pattern - other physical characteristics </li></ul>
    4. 4. General reasons for giving aerosol treatments <ul><li>II. to deliver cool bland aerosol: (primarily to the upper airway - MMAD of >/= 5 microns ) use sterile water or normal saline </li></ul><ul><li>to increase expectoration - can also use hypo and hypertonic saline ( note that systemic hydration - drinking water is the best way ) </li></ul><ul><li>to reduce airway swelling </li></ul><ul><li>post-op management of airways </li></ul><ul><li>croup </li></ul>
    5. 5. General reasons for giving aerosol treatments <ul><li>III. to deliver bland aerosol for sputum induction : ( MMAD of 1 - 5 microns ) use hypo - hyper or isotonic saline </li></ul><ul><li>to get C & S (culture and sensitivity ) </li></ul><ul><li>to get cytology </li></ul>
    6. 6. Hazards in Performing Aerosol Treatments <ul><li>Infection – aerosol particles can cross-contaminate the neb, the patient and the RCP, airborne microbes can cause nosocomial infections, (common organism- Pseudomonas aeruginosa ) change neb setup regularly* and WASH HANDS </li></ul>*per facility policy
    7. 7. Hazards <ul><li>Bronchospasm – cool and high-density aerosols can cause relative bronchospasm and increased airway resistance (especially in patients with preexisting resp. disease) </li></ul><ul><ul><li>Examples of some meds that may lead to bronchospasm are: acetylcysteine, antibiotics, steroids, cromolyn, ribavirin and distilled water </li></ul></ul><ul><ul><li>Monitor these patients closely and if you suspect bronchospasm, stay with the patient, attempt to calm the patient and contact the nurse to call doc </li></ul></ul>
    8. 8. Hazards <ul><li>Overhydration - long term administration (72 hours or more) with a bland aerosol, it is more serious in infants </li></ul><ul><ul><li>Saline may alter electrolytes </li></ul></ul><ul><li>Airway thermal injury – a problem with heated aerosols, monitor the temperature and do not let the water run dry </li></ul>
    9. 9. Hazards <ul><li>Airway obstruction from swollen secretions – make sure the patient can cough and does cough to get secretions out, if the patient is unable to generate a strong enough cough, you need to suction or assist with another bronchial hygiene method </li></ul>
    10. 10. Hazards <ul><li>Remember additional hazards from the medication </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Nervousness </li></ul></ul><ul><ul><li>Tremors </li></ul></ul><ul><ul><li>Thrush from steroids </li></ul></ul><ul><ul><li>Bronchospasm </li></ul></ul><ul><ul><ul><li>from steroids, </li></ul></ul></ul><ul><ul><ul><li>mucomysts, </li></ul></ul></ul><ul><ul><ul><li>antibiotics </li></ul></ul></ul><ul><ul><ul><li>Preservatives in some medications </li></ul></ul></ul>
    11. 11. Drug Calculations <ul><li>Convert from given dose to desired dose </li></ul><ul><li>Concentrated albuterol </li></ul><ul><li>5mg/ mL of concentrated albuterol </li></ul><ul><li>Unit dose of albuterol per MD order </li></ul><ul><li>5mg 2.5 mg </li></ul><ul><li>mL = ? </li></ul>
    12. 12. Drug Calculations <ul><li>Lidocaine dose </li></ul><ul><li>0.75 mg/kg? </li></ul><ul><li>210 pound male patient </li></ul>
    13. 13. Drug Calculations <ul><li>Convert pounds to kilograms </li></ul><ul><li>210 lbs divided by 2.2 (conversion factor) </li></ul><ul><ul><li>210/2.2=95.45 kg </li></ul></ul><ul><li>Multiply drug amount by weight in kg </li></ul><ul><ul><li>0.75 mg X 95.45 kg = 71.59 mg of medication </li></ul></ul>
    14. 14. Common Nebulized Meds <ul><li>albuterol 2.5 mg/ 3 mL NS (Proventil ® ) </li></ul><ul><li>Xopenex ® 1.25 mg/ 3 mL NS (levalbuterol) </li></ul><ul><ul><li>0.63mg/ 3mL </li></ul></ul><ul><ul><li>0.32 mg/ 3 mL </li></ul></ul><ul><li>Atrovent ® 0.5mg/ 2.5 mL (ipratropium bromide) </li></ul><ul><li>DuoNeb ® (ipratropium bromide 0.5 mg/albuterol Sulfate 3.0 mg) </li></ul><ul><li>Brovana ® 15 mcg/2mL (arformoterol) </li></ul>
    15. 15. Xopenex <ul><li>(Racemic) albuterol is a 50:50 mix of both the (S)- isomer and the (R)-isomer. </li></ul><ul><li>XOPENEX ® contains only the single (R)-isomer. The (R)-isomer is known to be the isomer responsible for the bronchodilation provided by racemic albuterol. </li></ul>
    16. 16. Drawing up medications
    17. 17. Drawing Up Medications <ul><li>Use appropriate size syringe </li></ul><ul><li>Clean surface of vial with alcohol wipe </li></ul><ul><li>Invert bottle with rubber stopper down and insert needle </li></ul><ul><li>Inject sufficient air to replace volume to be removed </li></ul><ul><li>Keep tip of needle below surface of liquid </li></ul><ul><li>Withdraw desired volume of fluid, monitoring for bubbles or air pockets -tap syringe? </li></ul>
    18. 18. Safety !! <ul><li>Do NOT recap the needle </li></ul><ul><li>Dispose of unsheathed needle appropriately </li></ul><ul><li>*Use needleless systems when possible </li></ul>
    19. 19. Equipment Needed to Give Treatments <ul><li>4 TYPES of aerosol treatments </li></ul><ul><li>1. SVN with meds </li></ul><ul><li>2. MDI/ DPI with or without spacer device for med delivery </li></ul><ul><li>3. USN / LVN for bland aerosol </li></ul><ul><li>4. USN / LVN or SVN for sputum induction </li></ul>
    20. 21. Equipment <ul><li>SVN -small volume nebulizer - gas powered with low flow air or O2 ( uses flowmeter, compressor and sometimes a squeeze bulb ) </li></ul><ul><li>Uses Bernoulli's principle - SVNs have a jet in which gas flows thru and as lateral pressure decreases, the med or other liquid is brought up thru a capillary tube, the liquid meets with the gas and aerosol is produced - particles are baffled to generate correct MMAD </li></ul>
    21. 22. Equipment <ul><li>There are many different types of SVN ( hand-held, used with IPPB circuit or MV </li></ul><ul><li>SVNs used with IPPB or MV (mechanical ventilation) are classified as either </li></ul><ul><ul><li>mainstream - the main flow of gas actually passes thru the aerosol generator (Pg 267 “White-Clinical book) </li></ul></ul><ul><ul><li>sidestream - in which the aerosol is injected into the main stream - most newer nebs can be used as one or the other </li></ul></ul><ul><li>Common hand-held type - uses a T-piece with a mouthpiece and a 50 cc reservoir ( retains aerosol for increased deposition ) </li></ul><ul><li>Can also use a mask ( aerosol, venti, face tent ) or adaptor for MV </li></ul>
    22. 23. SVN-Factors Affecting Performance <ul><li>1. Liquid within unit - 4 ml optimal ( SVNs provide more aerosol with this volume and flows of 6-8 L/m ) </li></ul><ul><li>2. Gas flow rate - 6-8 L/m clinically useful particles with average of 1 - 5 microns ) - as flow increases, particle size decreases, but flows above 8 L/m decrease the tx time, so pt. gets less med - flows less than 6 L/m take too long </li></ul><ul><li>3. Dead volume -fluid remaining in cup at the pt. in which no more aerosol is generated - (.5 -1.0 ml) as dead volume increases, more med stays in cup and the efficiency decreases - flick sides when device starts to sputter to get as much med to pt. as possible* </li></ul><ul><li>4. Particle size </li></ul><ul><li>5. Breathing pattern </li></ul>
    23. 24. SVN <ul><li>As the fluid level decreases, the diluent evaporates and the med concentration increases, esp. towards end of tx </li></ul><ul><li>SVNs only provide about 10 % of the med to the lower airways </li></ul><ul><li>Different brands available, so choose brand most beneficial for pt.’s condition and dz process </li></ul><ul><li>During MV- place SVN 18” from pt. </li></ul><ul><li>Some vents need filters ( Servo) </li></ul><ul><li>Finger control type - finger on port nebulizes , finger off port, no nebulization </li></ul><ul><li>Meds wasted with continuous nebulization </li></ul>
    24. 25. Breath Activated Neb <ul><li>Aero-Eclipse II BAN </li></ul><ul><li>Helps eliminate wasted medication </li></ul><ul><li>Less exposure to caregivers </li></ul><ul><li>Higher percentage of breathable particles </li></ul><ul><li>Shorter treatment time </li></ul><ul><li>Reduction of the number of treatment </li></ul>pg 818 Egan
    25. 26. Breath Enhanced Neb (Pari LC Jet plus) insert
    26. 27. Breath Enhanced Nebulizer inserted
    27. 28. Respiguard II <ul><li>For aerosolized Pentamidine delivery. Includes: Acorn II®, 7' kink-resistant supply tube, universal anti-drool ‘T’, mouthpiece, 6&quot; aerosol tube, nonported wye, 1-way valves and expiratory filter. </li></ul>inserted
    28. 29. PROCEDURE FOR ADMINISTERING AN AEROSOL TX WITH MED <ul><li>1. check the order - make sure dosages are WNL, check for tx frequency and when last tx was given, check labs ( K+ with cont. neb tx ), diagnostics, meds, H&P, and normal VS KNOW DIAGNOSIS </li></ul><ul><li>2. usual room entry - “ Hi Mrs. Miller, I’m from respiratory and I’m here to give you your breathing tx” wash hands, Don gloves, check arm ID, get equipment ready check to see when changed out last. </li></ul>
    29. 30. Procedure <ul><li>3. check VS to include : Pulse, RR, auscultate and BP - position pt. (full or semi-fowlers - obtain vital capacity, peak flow, FEV1 </li></ul><ul><li>4. get meds ready- measure correct amt., may be bottle with dropper (USE SYRINGE AND DRAW UP CORRECT AMOUNT) , pre-filled vials- glass or plastic , - check med or diluent name and check for exp. date , some meds have to be refrigerated, some meds can be kept at room temp. and some meds have to be made up by the pharmacy </li></ul>
    30. 31. Procedure <ul><li>5. Instruct pt. on breathing pattern - slow,normal breaths with a moderate deep breath thru mouth q1” and a breath hold of 4-10 secs - avoid hyperventilation - encourage diaphragmatic breathing which may be helpful </li></ul><ul><li>6. Turn on flow - 6 -8 l/m - check for adequate mist </li></ul><ul><li>7. Apply device (use appropriate device for individual pt. ) mouthpiece best device (including children over 3 ), but... may need mask or blow-by* </li></ul><ul><li>Monitor the pt. closely - watch for hyperventilation , problems with mask </li></ul>*some facilities do NOT allow blow by
    31. 32. Procedure <ul><li>watch for side effects of meds - ex. acetylcysteine - bronchospasm </li></ul><ul><li>sympathomimetics – tachycardia, hypertension, tremors, palpitations, N&V and nervousness </li></ul><ul><li>allergic reaction to drug -SOB , bronchospasm </li></ul><ul><li>IF HR INCREASES BY 20 BEATS STOP TX - pt. may already have an increased HR , if so, check with physician before giving tx </li></ul><ul><li>8. Check VS midway thru tx- ask pt. how they are feeling, the length of tx will vary TRY TO USE UP MED </li></ul><ul><li>9. Check VS again after tx and spirometry - check hospital policy for cleaning neb and storage </li></ul>
    32. 33. Procedure <ul><li>10. Have pt. cough and expectorate if possible - note amt. , color, consistency & smell of secretions uhhhh?yucckkkk! </li></ul><ul><li>11. Put room back together and ask it they need anything – (check with nurse - maybe NPO) </li></ul><ul><li>12. CHART - date, time started, type of tx, duration, meds & amt., position, complications, VS ( 80-85-84 ) include all, cough effort, secretions, signature and credentials </li></ul><ul><li>The above should be included for all types of aerosol txs </li></ul>
    33. 34. Large Volume Neb
    34. 35. Ultrasonic Nebulizer <ul><li>Car Power adapter </li></ul><ul><li>Rechargeable battery </li></ul><ul><li>Portable </li></ul><ul><li>Ease of Use </li></ul>
    35. 37. MDI <ul><li>MDIs are small, pressurized canisters with a mouthpiece that uses pressurized gas propellants - 80 -100 doses (varies with med ) - depression of the canister leads to a measured amt. of propellant carrying the med crystals to the pt.s open airway ( the propellants, ‘CFCs in the past, now most use HFAs ( hydrofluoroalkanes)’, high pressure causes rapid evaporation & dissipation while the med is aerosolized </li></ul><ul><ul><li>can be used inline MV circuit </li></ul></ul><ul><ul><li>if using Atrovent place in mouth to avoid glaucoma </li></ul></ul>
    36. 38. Metered Dose Inhalers <ul><li>MDI - the most important aspect for effectiveness is patient understanding of proper instruction and being able to follow the proper instruction </li></ul><ul><li>successful delivery of med depends on : </li></ul><ul><li>a. coordinating the actuation at the appropriate time </li></ul><ul><li>b. slow inspiratory flow </li></ul><ul><li>c. 4 -10 second breath hold at end inspiration </li></ul><ul><li>use the bronchodilator first -if using steroid gargle after & use spacer </li></ul><ul><li>wait at least one minute between puffs with 3 – 10” being optimal </li></ul>
    37. 39. Optimal Technique for pMDI <ul><li>Warm the MDI to body temperature </li></ul><ul><li>“ Prime” by activating into the air </li></ul><ul><li>Assure mouthpiece is clear </li></ul><ul><li>Open mouth technique* </li></ul><ul><ul><li>2 fingers from lips and mouth opened </li></ul></ul><ul><li>Closed mouth-lips around mouth piece </li></ul><ul><li>Breath out normally </li></ul>Egan pg 808 Box 36-1
    38. 40. Optimal Technique for pMDI <ul><li>Slowly begin to breath in-actuate the MDI </li></ul><ul><li>Continue to breath in to total lung capacity </li></ul><ul><li>Hold breath for up to 10 seconds </li></ul><ul><li>Wait at least 1 minute between puffs </li></ul><ul><li>Recap and store device </li></ul><ul><ul><li>Clean as required </li></ul></ul><ul><ul><li>Rinse mouth after some medications </li></ul></ul><ul><ul><li>Count puffs?* </li></ul></ul>
    39. 41. MDI <ul><li>Breath activated MDI’s (Autohaler) </li></ul><ul><ul><li>pirbuterol has a preferential effect on beta-2 adrenergic </li></ul></ul>
    40. 42. Frequent MDI’s <ul><li>albuterol </li></ul><ul><li>Xopenex </li></ul><ul><li>Atrovent </li></ul><ul><li>Flovent </li></ul><ul><li>Combivent </li></ul>
    41. 43. Brand Name Drug Name Proventil ® albuterol Xopenex ® levalbuterol Atrovent ® Ipratropium bromide Flovent ® flucticasone Combivent ® albuterol & ipratropium bromide
    42. 45. DPI (dry powder inhaler) <ul><li>DPIs ( dry powder inhalers ) - alternate method for certain med delivery - do not use CFCs - DPIs are breath-actuated (no need for coordination but must have sufficient inspiratory flow) ex. - Spinhaler, Rotohaler </li></ul><ul><ul><li>the device requires a gelatin capsule with powdered med - the delivery device opens the capsule and the pt. must inspire at a certain high flow in order to get the med into the airways </li></ul></ul><ul><ul><li>main problems with this delivery </li></ul></ul><ul><li>sufficient flows required </li></ul><ul><li> no reaction to powder </li></ul><ul><li>also cannot be used with MV as moisture would clump med </li></ul>
    43. 46. Brand Name Drug Name Serevent ® salmeterol Flovent ® Diskus fluticasone Advair Salmeterol & fluticasone Pulmocort Flexhaler budesonide
    44. 47. SPACERS AND CHAMBERS FOR MDIs <ul><li>Used to enhance aerosol delivery - there are many types available </li></ul><ul><li>Goals: </li></ul><ul><li>1. to decrease velocity of the propelled aerosol from MDI </li></ul><ul><li>2. to decrease inertial impaction </li></ul><ul><li>3. to decrease oropharyngeal deposition </li></ul><ul><li>4. to improve pt. synchronization </li></ul><ul><li>Spacers and chambers are partial reservoirs for medication </li></ul><ul><li>SPACERS DIFFER FROM CHAMBERS </li></ul><ul><li>spacers still require coordination </li></ul><ul><li>chambers have a one-way valve, so no med lost on exp. </li></ul><ul><li>chambers take 2 -3 additional puffs </li></ul><ul><li>they are also available with mask </li></ul><ul><li>can be used inline with MV </li></ul><ul><li>chamber or spacer mouthpiece should be placed in mouth </li></ul>
    45. 52. Medication Delivery in Children <ul><li>Not just little people (what dose is right?) </li></ul><ul><li>May pose special problems </li></ul><ul><ul><li>Uncooperative </li></ul></ul><ul><ul><li>Crying-quick inspiratory time with prolonged expiratory “cry” </li></ul></ul><ul><ul><li>Avoid medications in eyes </li></ul></ul><ul><ul><li>Avoid medicating other caregivers </li></ul></ul><ul><ul><li>Avoid blow-by* </li></ul></ul>*some facilities have policies against blow by
    46. 54. Medication Delivery in Children <ul><li>Most meds labeled for adults and children 6 years of age and older </li></ul><ul><li>Do they need twice as much? </li></ul><ul><li>Do they need half as much? </li></ul>