Respiratory: Inhalation Medication Delivery Devices
This Clinical Information Sheet has been developed to assist RACF staff, medical practitioners and relevant professionals (pharmacists, allied health clinicians) involved in the management of residential aged care patients with respiratory disease requiring inhaled medications. It can be used with the respiratory information sheets on Asthma and Chronic Obstructive Pulmonary Disease (COPD). It addresses issues relevant to residents and staff in RACF, particularly the:
This CIS covers:
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and Advance Care Plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Inhalation Medication Delivery Devices
Inhalation is the preferred route for medications prescribed for respiratory illness such as asthma and/or COPD, as there is a rapid response to medication delivered via inhalation, reduced side effects, and lower doses of medication can be used [1, 2].
Types of delivery devices
Inhaled medications can be delivered via a metered dose inhaler (MDI) or a nebuliser. Metered dose inhalers deliver the correct dose of medication through activating the inhaler. Aerosol inhalers and dry powder inhalers are both forms of MDI. Aerosol inhalers deliver the medication in a fine mist whilst dry powder inhalers deliver powdered medication [1-3]. Figure One outlines the types of devices available, and Table One shows the delivery devices available for specific inhaled medications.
Figure One: Types of delivery devices
Table One: Types of delivery devices available for inhaled medications [4]
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Medications
(by brand name)
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Puffer
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Autohaler
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Turbuhaler
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Accuhaler
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Nebules
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Aerolizer
|
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Relievers
|
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Airomir
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✔
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✔
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|
|
|
|
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Asmol
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✔
|
|
|
|
|
|
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Atrovent,
Atrovent Forte
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✔
|
|
|
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✔
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|
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Bricanyl
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|
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✔
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✔
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|
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Epaq
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✔
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|
|
|
|
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Ventolin
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✔
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|
|
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✔
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|
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Symptom controllers
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Foradile
|
|
|
|
|
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✔
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|
Oxis
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✔
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|
|
|
|
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Serevent
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✔
|
|
|
|
|
|
|
Preventers
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Flixotide
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✔
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|
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✔
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Intal
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✔
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|
|
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✔
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Intal Forte
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✔
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|
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|
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Qvar
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✔
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✔
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|
|
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Pulmicort
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|
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✔
|
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✔
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|
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Seretide
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|
|
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✔
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|
|
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Symbicort
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|
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✔
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|
|
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Tilade
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✔
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|
|
|
|
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Selecting a delivery device
The resident must be able to use the medication delivery device correctly to achieve a rapid response to medication, attain maximum benefits, and reduce medication side effects [1-3]. The general practitioner should consider the resident’s physical and cognitive abilities, e.g. arthritis, dementia, when selecting the most appropriate delivery device and inhaled medication. Table Two outlines benefits and disadvantages of various delivery devices.
Table Two: Benefits and disadvantages of inhaled medication delivery devices [4]
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Type of disorder
|
Benefits
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Disadvantages
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Aerosol Inhalers
|
|
Puffer
|
Can be used with a spacer device to improve amount of medication inhaled
Spacer device decreases coordination required
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Requires good coordination to time inhalation with canister depression (if not used with spacer)
Requires strength to depress the canister
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|
Autohaler
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Breath-activated so requires less coordination
|
|
|
Dry Powder Inhalers
|
|
Turbuhaler
Accuhaler
Aerolizer
|
Has indicator to alert when empty
Device activated by inhalation breath
No canister depression required
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Must hold device upright when loading to prevent medication falling out
Requires ability to take a deep breath
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|
Nebulisers
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|
Nebuliser
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Requires no coordination ability to use
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Requires access to power, and regular machine maintenance
Requires different parts, e.g. face mask, bowl, tubing, that need regular cleaning
Can be intimidating/claustrophobic for some residents
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Aerosol inhalers
Puffer
A puffer administers medications for respiratory disease in the form of a fine mist. When using a puffer, only one dose (one puff) of medication should be administered for each inspiration. As multiple doses are usually prescribed the resident will require more than one puff per administration [5]. Puffers can be taken using a closed or open mouth technique [3, 5-7] however it is recommended that older adults use a closed mouth technique as this maximises medication delivery to the lungs [8]. Some aerosol medications, e.g. Intal Forte CFC-Free; Ventolin CFC, have a sticky preparation and the puffer nozzle may become clogged. Follow the manufacturer’s instructions in caring for device [6].
Procedure for Administering Puffer Medications Using the Closed Mouth Technique[2, 3, 5, 7]
1. Remove the cap from the puffer mouthpiece. Hold the puffer upright and shake vigorously. Instruct the resident to hold his or her chin up and breathe out. Put the puffer mouthpiece in the resident’s mouth and instruct the resident to create a seal with his or her lips. Instruct the resident to breathe in through his or her mouth. Depress the aerosol container and administer one puff of medication as the resident continues to inhale. Instruct the resident to hold his or her breath for 10 seconds then exhale through his or her nose. If administering an inhaled corticosteroid, instruct the resident to rinse his or her mouth well to remove residual medication and decrease risk of oral candidiasis, throat irritation or hoarseness.
Spacers
A spacer is a device that looks like a wide plastic tube into which puffer medication is sprayed and held for subsequent inhalation by the resident [3]. Spacers increase the effectiveness of medication administration as they permit more of the medication to be inhaled [1, 2, 5, 8] and they decrease throat irritation that some individuals experience using a puffer [1]. It is recommended that older adults use spacers for medication administration as they require less coordination than using an inhaler alone [2, 8]. Spacers are also recommended for residents who require high doses of inhaled steroids as they reduce the residual medication in the mouth that may lead to oral candidiasis [6].
For infection control purposes each resident should have his or her own spacer. Before initial use and once every 2-4 weeks the spacer should be washed in warm water and diluted kitchen detergent and allow to air dry. DO NOT rinse or wipe dry [2, 3, 6, 7]. Before using the device again after washing activate 3-5 doses of the puffer medication into the spacer to prevent fluctuations in dosage due to changes in the electrostatic charge within the device [3]. Spacers should be replaced every 12 months [7].
Procedure for Administering Medications Via a Spacer [2-4, 7]
Assemble the spacer if required. Remove the cap from the puffer and shake the puffer well. Attach the puffer to the end of the spacer. If the resident uses a spacer with a mouthpiece, place the mouthpiece of the spacer in the resident’s mouth and instruct the resident to close his or her lips around it. If the resident uses a spacer with a facemask, place the facemask over the mouth and nose to ensure a good seal. Press down on the puffer canister once to release medication into the spacer. Instruct the resident to breathe in and out normally for about 4-5 breaths. Inhalation should commence as soon after activating the puffer as possible. To administer more medication, shake the puffer and repeat steps 3-6.
Autohaler
Autohalers are breath-activated aerosol inhalers that can be used by individuals who have poor technique or insufficient coordination to use puffers [2, 3, 6]. Once they are triggered a metered dose of medication is delivered and this is not dependent upon the individual’s inspiratory flow rate, unlike dry powder inhalers [6].
Procedure for Administering Medications Using an Autohaler [2, 4]
Remove the cover from the Autohaler mouthpiece. Hold the Autohaler in an upright position without blocking the vents at the base. Lift the grey lever up at the top and shake the device vigorously. Instruct the resident to hold his or her chin up and breathe out. Put the Autohaler mouthpiece in the resident’s mouth and instruct the resident to create a seal with his or her lips. Instruct the resident to breathe in through his or her mouth with a deep, steady breath for approximately 5 seconds or as long as possible. The Autohaler will fire a dose of medication automatically. Instruct the resident to hold his or her breath for 10 seconds then breathe out slowly through his or her nose. Return the grey lever to its original position. Wipe mouthpiece with a clean, dry tissue and replace cap.
Dry Powder Inhalers
Dry powder devices include [4]:
Turbuhaler; Accuhaler; and Aerolizer.
Turbuhaler and Accuhaler are breath-activated dry powder devices that contains a specific number of doses and a dose indicator that either highlights the number of doses left or indicates when the device is almost empty [2, 6]. When using a dry powder device a deep inhalation is required to get the medication into the lungs, therefore older individuals or those with severe asthma may have difficulties [2, 3]. Care should be taken to avoid contact with moisture or blowing into the dry powder device [2, 3].
Aerolizer (not commonly used) contains powdered medication in a capsule form that is released when the device is activated and the capsule is pierced [4].
Turbuhaler
Procedure for Administering Medications Using a Turbuhaler [2-4]
Unscrew and lift off the cap. Check the dose indicator before commencing. Hold the Turbuhaler upright. This prevents the medication from falling out. Twist the coloured base to the right and then to the left, until it clicks. Instruct the resident to exhale gently, but not blow into the Turbuhaler. Put the Turbuhaler mouthpiece in the resident’s mouth and instruct the resident to create a seal with his or her lips. Instruct the resident to breathe in through his or her mouth with a deep, steady breath for approximately 5 seconds or as long as possible. Remove the Turbuhaler from the resident’s mouth before breathing he or she exhales. Wipe mouthpiece with a clean, dry tissue and replace cap.
Accuhaler
Procedure for Administering Medications Using an Accuhaler [2]
Hold the Accuhaler by its base in one hand. Place the thumb of the other hand in the thumb grip. Open the Accuhaler by pushing the thumb grip around until it clicks. Slide the lever until it clicks. Instruct the resident to exhale gently, but not blow into the Accuhaler. Put the Accuuhaler mouthpiece in the resident’s mouth and instruct the resident to create a seal with his or her lips. Instruct the resident to breathe in through his or her mouth with a deep, steady breath for approximately 5 seconds or as long as possible. Remove the Accuhaler from the resident’s mouth and instruct him or her to hold breath for approximately 10 seconds. Instruct the resident to exhale slowly. Wipe mouthpiece with a clean, dry tissue and close the Accuhaler.
Nebulisers
A nebuliser pump is used to administer medication that comes in a liquid form. Medication is diluted in saline, and air is pumped through the liquid under pressure to produce a vapour which the resident inhales via a mask or mouthpiece [2, 3, 5, 9]. Although MDIs with spacers have been shown to be as effective in medication administration as nebulisers, some older adults may require nebuliser therapy due to poor technique or lack of cooperation in using other medication administration devices or may prefer nebulised medications due to the increased moisture [5, 8, 10].
Mouth pieces, face masks and nebuliser bowls should be washed in warm water after use or daily, allowed to air dry and stored in an airtight container. Once a week the mask, mouthpiece and bowl should be soaked in a disinfectant. Nebuliser bowls are disposable and need to be replaced regularly [6, 9]. Pumps should be serviced every 6-12 months (by the RACF’s pharmacist or Asthma Victoria) to ensure that an adequate airflow is produced for effective delivery of medication [6, 9].
Procedure for Administering Medications Using a Nebuliser [3, 5, 9]
Check the medication orders for the administration of medication by aerosol noting the strength of solution and the length of time over which the medication is to be administered. Place the nebuliser on a firm clean surface to allow for smooth running. Explain the procedure to the resident. Attach the oxygen nipple to the oxygen flowmeter. Undo the top of the nebuliser and add solution to be nebulised. Medication may be in pre-measured and pre-diluted dosages, or medication may be measured using a dropper and then diluted in the ordered amount of saline. Replace top of nebuliser and attach tubing to oxygen nipple and base of nebuliser. Connect mask to top of nebuliser. Turn oxygen flow to at least 8 litres per minute and check that mist is issuing from the facemask. Apply facemask to the resident and instruct him or her to breathe normally through the mouth to achieve optimal therapeutic effect from medication. A nebuliser pump should take approximately 10 minutes to administer medication, and approximately 80% of the medication should be nebulised in the first 8 minutes of administration.
Oxygen therapy
Oxygen therapy supplements normal respiration with higher concentrations of oxygen in the inhaled air. Oxygen therapy can be delivered by either a cylinder, concentrator or liquid oxygen system [11, 12]. Table Four summarises the characteristics of these oxygen delivery systems.
Table Four: Characteristics of oxygen delivery systems [11, 12]
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Type
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Oxygen rate
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Method of operation
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Comments
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Oxygen cylinders
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100% oxygen delivered at all flow rates
Oygen delivery only on demand is possible
|
Contain compressed oxygen gas
|
Electronic conservation devices are required for oxygen supply on demand which reduces overall oxygen consumption
Recommended for intermittent oxygen use or where power supply is poor
|
|
Oxygen concentrators
|
Delivers 90%–95% oxygen at a flow rate of 4-5 L/min
Pecentage of oxygen decreases as flow rate is increased
|
Extracts nitrogen from room air increasing oxygen concentration
|
Most cost effective delivery method
Do not have the pressure required for administering nebulised medication
Backup cylinder should be available in case of concentrator breakdown or power failure
|
|
Liquid oxygen systems
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100% oxygen delivered at all flow rates
|
Liquid oxygen is delivered through coils in which it vaporises to a gas
|
Requires a storage tank from which a smaller tank is filled for use, especially for ambulatory residents
|
Oxygen can be delivered to the resident using either a face mask or nasal prongs. Older adults, particularly those with cognitive impairments, often experience claustrophobia using a face mask and may prefer nasal prongs. Nasal prongs are less effective if the resident has a blocked nose or sinusitis. The percentage of oxygen delivered is adjusted at the adjustable flow rate from the outlet.
Oxygen use precautions
Oxygen promotes combustion and can become a fire hazard if stored or used incorrectly. All staff members, residents and relatives should be educated on the risk of fire when using oxygen therapy [13]. Basic safety precautions include:
Do not use or store oxygen systems within five metres of any open flame or heat source. Do not allow any smoking in the same room as an oxygen system. Do not use more than 15 metres of oxygen tubing as this reduces the concetration of oxygen the resident receives. Oxygen equipment should not be exposed to electrical appliances, e.g. electric razors, hair dryers, electric blankets Do not use aerosol cans or sprays near the oxygen system as these products are flammable. Secure loose cords and tubing to prevent accidental falls.
Sources of Information
Where to go for more information
Asthma Foundation of Victoria.
The Asthma Foundation of Victoria is a community-funded, not-for-profit organisation that provides advice, counselling, education and training to people with asthma, their carers, health professionals, first aiders and the community.
The Asthma Foundation of Victoria provides innovative training programs, a wide range of information sheets and brochures, the helpline and an informative website.
Contact: 9326 7088, or 1800 645 130 (Helpline)
Website: http://www.asthma.org.au/
National Asthma Council
The National Asthma Council Australia is a non-profit organisation, which serves aims to create awareness in the community about asthma and provide information about asthma. The organisation provides information about asthma for health professionals, asthmatics, and the general community.
Contact: (03) 8699 0476 or 1800 032 495 (Hotline)
Website: http://www.nationalasthma.org.au/index.htm
References
Sims, J, Guidelines for Treating Asthma. Dimensions of Critical Care Nursing, 2003. 22(6): p. 247-250. Asthma Australia, Asthma medications and delivery devices. 2003, Canberra: Asthma Australia. eTG, Therapeutic Guidelines: Respiratory, in http://www.tg.com.au (accessed August 2006), eTG. 2006 Asthma Foundation of Australia, (AFA), Asthma medications and delivery devices. 2005, Canberra: Asthma Foundation of Australia. Joanna Briggs Institute, Aged Care Practice Manual. 2nd ed. 2003, Adelaide: JBI. National Asthma Council Australia, Asthma Management Handbook 2002. 2002, Canberra: Commonwealth Government Department of Health and Ageing. Scottish Intercollegiate Guidelines Network and British Thoracic Society, British guidelines on the management of asthma. 2003, London: SIGN and BTS. National Institutes of Health (National Heart Lung and Blood Institutes) Considerations for Diagnosing and Managing Asthma in the Elderly. 1996, New York: U.S. Department of Health and Human Services. Asthma Victoria, Nebulisers, in http://www.asthma.org.au/informationsheets/nebulise.doc (accessed March 2004), Victoria, Asthma. 2000 National Institutes of Health (National Heart Lung and Blood Institutes), Practical guide for the diagnosis and management of asthma. 1997, New York: U.S. Department of Health and Human Services. Australian Lung Foundation, (ALF),Thoracic Society of Australia and New Zealand, (TSANZ), The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2006. 2006, Australian Lung Foundation, (ALF). p. 66. eTG, Therapeutic Guidelines: COPD, in http://www.tg.com.au (accessed April 2006), eTG. 2005 National Institute for Clinical Excellence, (NICE), Management of chronic obstructive pulmonary disease in adults in primary and secondary care. 2004, National Institute for Clinical Excellence, (NICE): London. p. 54. National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
The information presented is developed from level I evidence produced by the National Asthma Association Australia, Scottish Intercollegiate Guidelines Network , National Institute for Clinical Excellence (UK) and British Thoracic Society, as well as level IV evidence produced by the National Heart Lung and Blood Institutes, USA specific to asthma in the elderly.
The following table outlines the level of evidence of each reference:
|
|
Reference |
Year |
Level of Evidence |
1. |
Sims, J, Guidelines for Treating Asthma. Dimensions of Critical Care Nursing, 2003. 22(6): p. 247-250. |
2003 |
Level IV C evidence |
2. |
Asthma Australia, Asthma medications and delivery devices. 2003, Canberra: Asthma Australia. |
2003 |
Level IV C evidence |
3. |
eTG, Therapeutic Guidelines: Respiratory, in http://www.tg.com.au (accessed August 2006), eTG. 2006 |
2006 |
Level IV C evidence |
4. |
Asthma Foundation of Australia, (AFA), Asthma medications and delivery devices. 2005, Canberra: Asthma Foundation of Australia. |
2005 |
Level IV C evidence |
5. |
Joanna Briggs Institute, Aged Care Practice Manual. 2nd ed. 2003, Adelaide: JBI. |
2003 |
Level IV C evidence |
6. |
National Asthma Council Australia, Asthma Management Handbook 2002. 2002, Canberra: Commonwealth Government Department of Health and Ageing. |
2002 |
Level I evidence |
7. |
Scottish Intercollegiate Guidelines Network and British Thoracic Society, British guidelines on the management of asthma. 2003, London: SIGN and BTS. |
2003 |
Level I evidence |
8. |
National Institutes of Health (National Heart Lung and Blood Institutes) Considerations for Diagnosing and Managing Asthma in the Elderly. 1996, New York: U.S. Department of Health and Human Services. |
1996 |
Level IV C evidence |
9. |
Asthma Victoria, Nebulisers, in http://www.asthma.org.au/informationsheets/nebulise.doc (accessed March 2004), Victoria, Asthma. 2000 |
2004 |
Level IV C evidence |
10. |
National Institutes of Health (National Heart Lung and Blood Institutes), Practical guide for the diagnosis and management of asthma. 1997, New York: U.S. Department of Health and Human Services. |
1997 |
Level IV C evidence |
11. |
Australian Lung Foundation, (ALF),Thoracic Society of Australia and New Zealand, (TSANZ), The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2006. 2006, Australian Lung Foundation, (ALF). p. 66. |
2006 |
Level IV C evidence |
12. |
eTG, Therapeutic Guidelines: COPD, in http://www.tg.com.au (accessed April 2006), eTG. 2005 |
2006 |
Level IV C evidence |
13. |
National Institute for Clinical Excellence, (NICE), Management of chronic obstructive pulmonary disease in adults in primary and secondary care. 2004, National Institute for Clinical Excellence, (NICE): London. p. 54. |
2004 |
Level I evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using an adapted version of the NHMRC (1995) [14] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (Level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
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