Inhaled Medications Administration

Inhaled medications treat asthma, chronic obstructive pulmonary disease (COPD), and other pulmonary disorders. They go in through aerosol sprays, mists, or powders, target the respiratory system directly, and carry minimal systemic side effects, though systemic effects do occur.

What are Inhaled Medications?

These are drugs delivered straight to the lungs or respiratory tract by inhalation for localized treatment. They include bronchodilators to open airways, corticosteroids to reduce inflammation, and other drugs for respiratory symptoms.

Types of Inhaled Medications

• Bronchodilators relax the muscles around the airways to open passages and improve airflow.
  • Short-acting: albuterol (salbutamol), levalbuterol.
  • Long-acting: salmeterol, formoterol, tiotropium.
• Corticosteroids (steroids) reduce airway inflammation to prevent and control asthma attacks and other inflammatory lung conditions.
  • Examples: fluticasone, budesonide, beclomethasone.
• Combination inhalers pair a bronchodilator and a corticosteroid in one device.
  • Examples: fluticasone/salmeterol, budesonide/formoterol, fluticasone/vilanterol.
• Anticholinergics relax airway muscles and reduce mucus production.
  • Examples: ipratropium bromide, tiotropium.
• Mast cell stabilizers prevent the release of substances that cause airway inflammation and allergic reactions.
  • Examples: cromolyn sodium, nedocromil.
• Antibiotics (in some cases) are inhaled to treat respiratory infections like chronic bronchitis or cystic fibrosis-related infections.
  • Examples: tobramycin inhalation solution, aztreonam inhalation solution.
• Mucolytics break down airway mucus so it is easier to cough up.
  • Examples: dornase alfa (cystic fibrosis), hypertonic saline.

Indications

• Asthma
• COPD (chronic obstructive pulmonary disease)
• Bronchiectasis
• Cystic fibrosis
• Respiratory infections (e.g., bronchitis)

Types of Inhaled Devices

1. Nebulizers

A nebulizer holds liquid medication in a reservoir and an aerosol generator turns it into droplets, directed to the patient through a mouthpiece, mask, tent, nasal prongs, or artificial airway. Good for larger doses over a longer period. Three common types:

• Jet nebulizers use compressed air to make a fine mist. Bulky, need a power source, and noisy, but effective across a wide range of medications.
• Ultrasonic nebulizers use ultrasonic waves. Quieter and more portable than jet nebulizers, but not suited to all medications, especially heat-sensitive ones.
• Mesh nebulizers push medication through a fine mesh. Small, portable, and silent, but more expensive and needing regular cleaning to keep the mesh functional.

2. Metered-Dose Inhalers (MDIs)

An MDI delivers a measured dose into the lungs with each puff, using a chemical propellant to carry the medicine. The visible spray is propellant plus medication.

The propellants are primarily hydrofluoroalkanes (HFAs) like HFA-134a and HFA-227, which replaced older CFCs and deliver an accurate, efficient fine mist.

3. Dry Powder Inhalers (DPIs)

DPIs are tube- or disk-shaped with a mouthpiece and hold a dry powder formulation. Inhaling delivers fine powder to the lungs. Unlike MDIs, DPIs need a forceful inhalation, which makes precise dosing harder. Two types:

• Single-dose DPIs require loading a new dose before each use, usually in capsules or blister packs.
  • Examples: HandiHaler, Aerolizer.
• Multi-dose DPIs hold multiple doses in a reservoir or pre-metered, allowing several uses before a refill.
  • Examples: Diskus, Turbohaler, Ellipta.

4. Soft Mist Inhalers (SMIs)

SMIs, also called Respimat inhalers, dispense a fine mist that disperses gradually and lingers longer than an MDI aerosol. Press the side button while inhaling to release the dose. A built-in counter tracks remaining doses and turns red when nearly empty, and the device locks once all medication is dispensed.

Steps for Administering Inhaled Medications

Verify the physician's order for the correct medication and dosage, perform hand hygiene, document the treatment, and report anything unusual to the physician.

How to Use a Nebulizer

Equipment: nebulizer machine (compressor), nebulizer cup and mouthpiece or mask, prescribed medication, saline (if needed), clean water for rinsing, towel or tissues.

1. Measure the prescribed dose into the nebulizer cup, diluting with saline if prescribed.

2. Connect the mouthpiece or mask to the cup and the cup to the compressor.

3. Sit the patient comfortably upright to aid deep inhalation and lung expansion.

4. Turn on the compressor to create the aerosol mist.

5. Have the patient place the mouthpiece in the mouth or the mask over nose and mouth and breathe normally for continuous delivery over the treatment.

6. Continue until the medication is used up, typically 5-10 minutes.

7. Turn off the machine when finished.

8. Disassemble and rinse the components with clean water and air dry to prevent residue buildup and infection.

How to Use a Metered-Dose Inhaler (MDI)

Follow the manufacturer's instructions for the specific brand; general guidelines follow.

Equipment: MDI, spacer (if prescribed), prescribed medication, towel or tissues.

1. Remove the cap from the mouthpiece to clear the medication path.

2. Shake the inhaler vigorously for 5-10 seconds to mix the medication and prevent settling, so each dose is accurate.

3. Attach the spacer if prescribed, which improves delivery for patients with coordination difficulty and cuts deposition in the mouth and throat.

4. Have the patient sit or stand upright to improve lung expansion and breathing.

5. Have the patient exhale completely to make room in the lungs.

6. Place the mouthpiece (or spacer) between the lips and have the patient seal tightly to prevent leakage and direct medication into the airway.

7. Have the patient inhale slowly and deeply while pressing the inhaler to release the dose, coordinating actuation with inhalation to drive medication deep into the lungs.

8. Have the patient hold the breath about 10 seconds so the medication settles and absorbs.

9. Have the patient exhale slowly and gently.

10. If a second dose is prescribed, wait 30 seconds to 1 minute before repeating, so the first dose takes effect.

11. Replace the cap and wipe the mouthpiece with a clean, dry tissue if needed.

12. Document the medication, dose, time, and observations.

How to Use a Dry Powder Inhaler (DPI)

Follow the manufacturer's instructions; general guidelines follow.

Equipment: DPI, prescribed medication, towel or tissues.

1. Remove the cap.

2. Load the prescribed dose per the manufacturer's instructions.

3. Have the patient sit or stand upright.

4. Have the patient exhale completely.

5. Place the mouthpiece between the lips with a tight seal.

6. Have the patient inhale forcefully and deeply so the dry powder reaches the lower airways.

7. Have the patient hold the breath about 10 seconds to let the medication settle and absorb.

8. Have the patient exhale slowly and gently.

9. Replace the cap and wipe the mouthpiece with a clean, dry tissue if needed.

How to Use a Soft Mist Inhaler (SMI)

Follow the manufacturer's instructions; general guidelines follow.

Equipment: SMI, prescribed medication, towel or tissues.

1. Hold the inhaler upright with the cap closed, and turn the clear base a half turn to the right until it clicks to prime it.

2. Open the cap.

3. Have the patient breathe out slowly and completely.

4. Place the mouthpiece in the mouth, holding the inhaler horizontally and pointing toward the back of the throat, to direct medication to the airways.

5. Have the patient seal the lips around the mouthpiece.

6. Have the patient take a slow, deep breath while pressing the side button, continuing to inhale for three to five seconds.

7. Have the patient hold the breath for ten seconds to retain the medicine in the lungs.

8. Remove the inhaler and have the patient exhale slowly.

9. Replace the cap.

Nursing Considerations

1. Prime a new MDI before first use. Shake for five seconds, press the canister with your index finger pointed away from the face to keep medication out of the eyes, then repeat the shake-and-press three more times to administer four doses.

2. Rinse the mouth after steroid inhalation to reduce the risk of oral thrush and throat irritation.

3. Use a spacer or chamber to help inhale the aerosol, which improves lung delivery by reducing the need to coordinate inhalation with actuation.

4. If a bronchodilator and a steroid are both ordered, give the bronchodilator first so it widens the airways and lets the steroid penetrate deeper.

5. Some DPIs need a capsule inserted and pierced, others a lever rotated to disperse the medication properly.

6. Store DPI medications in a cool, dry place. Humidity makes the powder clump, which obstructs the device and cuts effectiveness.

7. Inhaled steroids in COPD patients may raise infection risk, including pneumonia, through their immunosuppressive effect on the lungs.

8. DPIs are contraindicated in severe asthma or COPD and in cognitive or dexterity impairment, since these patients cannot generate the inspiratory flow to draw the medication, leading to ineffective delivery.