Handheld inhalers include the metered dose inhaler (or nebulizer), the turbo-inhaler, and the nasal inhaler. These devices deliver 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 are bronchodilators, used to improve airway patency and facilitate mucous drainage; mucolytics, which attain a high local concentration to liquefy tenacious bronchial secretions; and corticosteroids, used to 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 necessary to assemble a turbo-inhaler. Specific inhalant drugs 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, turbo-inhaler, or nasal inhaler • prescribed medication • normal saline solution (or another appropriate solution) for gargling • optional: emesis basin. (See Types of handheld inhalers)
Implementation
Verify the order on the patient's medication record by checking it against the physician's order.
Wash your hands.
Check the label on the inhaler against the order on the medication record. Verify the expiration date.
Confirm the patient's identity by asking his name and by checking his name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Explain the procedure to the patient.
Using a metered dose inhaler
Shake the inhaler bottle to mix the medication and aerosol propellant.
Remove the mouthpiece and cap. Note: 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 place the mouthpiece in his mouth and close his lips around it.
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 normal saline solution, 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.
Using a turbo-inhaler
Hold the mouthpiece in one hand, and with the other hand, slide the sleeve away from the mouthpiece as far as possible.
Unscrew the tip of the mouthpiece by turning it counterclockwise.
Firmly press the colored portion of the medication capsule into the propeller stem of the mouthpiece.
Screw the inhaler together again securely.
Holding the inhaler with the mouthpiece at the bottom, slide the sleeve all the way down and then up again to puncture the capsule and release the medication. Do this only once.
Have the patient exhale and tilt his head back. Tell him to place the mouthpiece in his mouth, close his lips around it, and inhale once—quickly and deeply—through the mouthpiece.
Tell the patient to hold his breath for several seconds to allow the medication to reach the alveoli. (Instruct him not to exhale through the mouthpiece.)
Remove the inhaler from the patient's mouth, and tell him to exhale as much air as possible.
Repeat the procedure until all the medication in the device is inhaled.
Have the patient gargle with normal saline solution, if desired, to remove medication from the mouth and back of the throat. Be sure to provide an emesis basin if the patient needs one.
Discard the empty medication capsule, put the inhaler in its can, and secure the lid. Rinse the inhaler with warm water at least once a week.
Using a nasal inhaler
Have the patient blow his nose to clear his nostrils.
Shake the medication cartridge and then insert it in the adapter. (Before inserting a refill cartridge, remove the protective cap from the stem.)
Remove the protective cap from the adapter tip.
Hold the inhaler with your index finger on top of the cartridge and your thumb under the nasal adapter. The adapter tip should be pointing toward the patient.
Have the patient tilt his head back. Then tell him to place the adapter tip into one nostril while occluding the other nostril with his finger.
Instruct the patient to inhale gently as he presses the adapter and the cartridge together firmly to release a measured dose of medication. Be sure to follow the manufacturer's instructions. With some medications, such as dexamethasone sodium phosphate (Turbinaire), inhaling during administration isn't desirable.
Tell the patient to remove the inhaler from his nostril and to exhale through his mouth.
Shake the inhaler, and have the patient repeat the procedure in the other nostril.
Have the patient gargle with normal saline solution to remove medication from his mouth and throat.
Remove the medication cartridge from the nasal inhaler, and wash the nasal adapter in lukewarm water. Let the adapter dry thoroughly before reinserting the cartridge.
Special considerations
When using a turbo-inhaler or nasal inhaler, make sure the pressurized cartridge isn't punctured or incinerated. Store the medication cartridge below 120° F (48.9° C).
If you're using a turbo-inhaler, keep the medication capsules wrapped until needed to keep them from deteriorating.
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.
Teach the patient how to use the inhaler so that he can continue treatments himself after discharge, if necessary. Explain that overdosage—which is common—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 physician determine the drug's effectiveness. Also, note whether the patient uses an unusual amount of medication—for example, more than one cartridge for a metered-dose nebulizer 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 allows the bronchodilator to open the air passages for maximum effectiveness.
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.