Administration of Bronchodilators


Bronchodilators may be administered in several forms. These include nebulised, powdered and metered dose inhalers (MDI). Depending on the device used, there are several considerations to take into account to successfully administer a bronchodilator dose.

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Figure 18. Nebuliser mask. Source http://www.mdsnq.com.au




Nebulisers work by atomising a liquid into aerosol through the application of pressurised air or oxygen. This makes the device versatile in that it can administer a variety of medications and some in combination, for example Salbutamol and ipratropium. They can also administer nebulised saline to assist with mucous plugs.

Nebulisers can be provided from piped air or oxygen in the acute care setting, however they can also be used at home with the assistance of a nebuliser pump or machine. They are relatively easy to use and are commonly used during the acute phase of an exacerbation of COPD due to the length of time they provide an aerosol for and the lack of requirement to have a metered dose inhaler technique (Yawn, 2011: 124).



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Figure 19. Nebuliser pump. Source http://www. acaciamedical.com.au


Nebuliser masks should be cleaned thoroughly after each use to ensure efficient running and administration of the complete dose of medication the next time it is used. Masks should be disconnected from the tubing, pulled apart and washed in a mild soapy detergent such as dishwashing liquid. The following link will provide more information on how to care for a nebuliser. Whilst it is predominantly consumer information on care of a nebuliser pump system for home use, the principles remain the same. You may even find this information useful give to your patients if they use a nebuliser at home.

http://www.similima.com/ppt/medicine/pm6.pdf

To ensure efficient operation of the device, always check tubing and connections to ensure that they are sealed. Where piped air is used in the acute setting, the air level should be delivered at 10 litres/minute to ensure adequate misting of the solution. Remember that if your patient is on oxygen, the mask can be placed over the top of nasal prongs for the short time it is required.

Metered dose inhalers (MDI)
Pressurised MDI (pMDI)

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Figure 20. Metered dose inhaler. Source http://www.asthma.about.com





As the name suggests, (pMDIs) deliver a pressurised metered dose with each of the canister. The expelled gas consists of an inert propellant and the active drug. One of their disadvantages when compared with nebulisers is that they require a technique to efficiently receive a dose. Colice (2009: 455) argues that a nebuliser can provide a larger dose that gets further into the bronchi. There is little evidence that supports this theory however, and although each pressurised dose of an MDI delivers a lesser dose, there is capacity for a rescue dose in the form of six puffs at a time. Boyd and Stuart (2005: 641-642) argue that there is no statistically significant difference between using an MDI with a spacer and a nebuliser, and that there is some evidence that supports regular use of an pMDI with spacer at home has a tendency to eliminate or reduce the need for lengthy acute hospitalisation.






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Figure 21. Spacer with MDI attached. Source http://www.archive.student.bmj.com






Click on the link to the Canadian asthma association to learn how to use and care for a spacer.


http://www.asthma.ca/adults/treatment/spacers.php


As mentioned previously, there is a technique required for the type of inhaler prescribed. The following link to the national asthma council of Australia will show you demonstration videos to improve your own inhaler technique to better educate your patients


http://www.nationalasthma.org.au/content/view/594/1028/


In addition, I would encourage you to read the following article

http://www.nationalasthma.org.au/images/stories/manage/pdf/Inhaler_technique_in_adults_with_asthma_or_COPD.pdf


Importantly, spacers should be dismantled and washed in mild detergent such as dishwashing detergent before use to remove static charge within the barrel if the spacer. This will ensure that the full dose of medication is administered and none adheres to the spacer wall.


There are several limitations to using an pMDI. Technique may be difficult if the patient has physical limitations preventing them from using an MDI. In addition, it may be necessary to carry a second unit as some MDI’s do not have an indicator to inform the user when they are about to expire. Colice (2009: 456) argues that where administration technique is poor, there may be a less effective dose administered. In addition to this argument however might be added that compliance might be an issue, especially where dosage is missed due to social engagements or socioeconomic .

Powdered dose inhalers (DPI)

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Figure 22. Dry powder inhalers. Source http://www.umm.edu



Dry powder inhalers are a form of MDI. They contain dry powder and the medications contained in them are usually long lasting making the need for their use usually once or twice per day. The technique for using a dry powder inhaler is to simply exhale and then to place mouth over mouthpiece whilst inhaling. The advantage of such a system is that it doesn’t require the technique or coordination that a pMDI would require. DPI contain medications that are generally long acting bornchodilators (LABA).


The following link will provide you with the techniques and care required for both turbohalers and accuhalers

http://www.mihsr.monash.org/hfk/pdf/asthmadrypowderinhalers.pdf


Tiotropium inhalers are slightly different. They function by inserting a capsule into the device and piercing the capsule to access the powder.

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Figure 23. Spiriva handihaler. Source http://www.breathingbetterlivingwell.com



To learn more about the use of Tiotropium see the following link


http://www.spiriva.com/about-spiriva/using-spiriva.html



The final item to consider in relation to administration of bronchodilators is to ensure appropriate mouth care. Patients should always rinse their mouths post administration of medications. In addition, patients should avoid administering medications prior to meals, as this can affect the taste of food.