METERED-DOSE INHALER USE

A metered-dose inhaler delivers topical medications to the respiratory tract, producing local and systemic effects. The mucosal lining of the respiratory tract absorbs the inhalant almost immediately. Examples of common inhalants include bronchodilators, which improve airway patency and facilitate mucous drainage; mucolytics, which attain a high local concentration to liquefy tenacious bronchial secretions; and corticosteroids, which decrease inflammation.

The use of these inhalers may be contraindicated in patients who can’t form an airtight seal around the device and in patients who lack the coordination or clear vision to assemble the inhaler. Some patients use a spacer to assist them with the airtight seal. Specific inhalants may also be contraindicated. For example, bronchodilators are contraindicated if the patient has tachycardia or a history of cardiac arrhythmias associated with tachycardia.

Equipment

Patient’s medication record and chart metered-dose inhaler and prescribed medication -normal saline solution (or another appropriate solution) for gargling  Optional: emesis basin.

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Implementation

-Verify the order on the patient’s medication record by checking it against the doctor’s order.

-Perform hand hygiene.

-Check the label on the inhaler against the order on the medication record. Verify the expiration date.

-Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.5

-If your facility uses a bar code scanning system, be sure to scan your identification badge, the patient’s identification bracelet, and the medication’s bar code.

-Explain the procedure to the patient. Answer any questions to decrease anxiety and increase cooperation.

-Shake the inhaler bottle to mix the medication and aerosol propellant.

-Remove the mouthpiece and cap. Keep in mind that some metered-dose inhalers have a spacer built into the inhaler. Pull the spacer away from the section holding the medication canister until it clicks into place.

-Insert the metal stem on the bottle into the small hole on the flattened portion of the mouthpiece. Then turn the bottle upside down.

- Have the patient exhale; then have him place the mouthpiece in his mouth and close his lips around it (as shown below).

As you firmly push the bottle down against the mouthpiece, ask the patient to inhale slowly and to continue inhaling until his lungs feel full. This action draws the medication into his lungs. Compress the bottle against the mouthpiece only once.

-Remove the mouthpiece from the patient’s mouth and tell him to hold his breath for several seconds to allow the medication to reach the alveoli. Then, instruct him to exhale slowly through pursed lips to keep the distal bronchioles open, allowing increased absorption and diffusion of the drug and better gas exchange.

-Have the patient gargle with water, if desired, to remove medication from the mouth and back of the throat. (The lungs retain only about 10% of the inhalant; most of the remainder is exhaled,but substantial amounts may remain in the oropharynx.)

-Rinse the mouthpiece thoroughly with warm water to prevent accumulation of residue.

-Perform hand hygiene.

-Document the procedure

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Special considerations

Spacer inhalers may be recommended to provide greater therapeutic benefit for children and for patients who have difficulty with coordination. A spacer attachment is an extension to the inhaler’s mouthpiece that provides more dead-air space for mixing the medication. Some inhalers have built-in spacers.

Patient Teaching

Teach the patient how to use the inhaler so that he can continue treatments himself after discharge, if necessary. Explain that overdosage, which commonly occurs, can cause the medication to lose its effectiveness. Tell him to record the date and time of each inhalation as well as his response to prevent overdosage and to help the doctor determine the drug’s effectiveness. Also, note whether the patient uses an unusual amount of medication—for example, more than one cartridge every 3 weeks. Inform the patient of possible adverse reactions.

If more than one inhalation is ordered, advise the patient to wait at least 2 minutes before repeating the procedure.

If the patient is also using a steroid inhaler, instruct him to use the bronchodilator first and then wait 5 minutes before using the steroid. This process allows the bronchodilator to open the air passages for maximum effectiveness.

Complications

Complications are related to the medication being administered.

Documentation

Record the inhalant administered as well as the dose and time. Note any significant change in the patient’s heart rate and any other adverse reactions.

Reference Lippincott Nursing Procedure