Respiratory procedures: Use of a nebuliser In the healthcare setting a nebuliser is a small device that can convert a drug from a solution into an aerosol form by means of a compressor/compressed gas source. Abstract Nebulisation creates a mist of drug particles that can be inhaled via a face mask or mouthpiece (Currie and Douglas, 2007). Bronchodilators are the most common nebulised drugs but many others can be nebulised, including steroids and antibiotics. HOW A NEBULISER WORKS The conventional nebuliser works by a flow of gas (oxygen or air) passing through a very small hole (venturi). Rapid expansion of air causes a negative pressure that sucks the nebulised fluid up the feeding tube system where it is atomised and inhaled (O’Callaghan and Barry, 1997). The proportion of the nebulised solution that reaches the lungs is approximately 12% (Rees and Kanabar, 2006), which is why nebulised doses of drugs are higher than those administered via an aerosol inhaler. MEDICATIONS ADMINISTERED Medications that are commonly administered through a nebuliser include bronchodilators (for example, salbutamol), anticholinergics (for example, ipratropium bromide), corticosteroids (for example, beclometasone) and normal saline. Indications The main indications are delivery of: - A bronchodilator or anticholinergic drug to a patient with an acute exacerbation of asthma or chronic obstructive airway disease (such as COPD); - A bronchodilator or anticholinergic drug regularly to a patient with severe asthma or reversible airways obstruction in whom regular high doses have been shown to be beneficial; - Prophylactic medication to a patient who has difficulty using other inhalational devices; - An antibiotic to a patient with a chronic purulent chest infection; - Pentamidine for the prophylaxis and treatment of pneumocystis pneumonia (British Medical Association/Royal Pharmaceutical Society of Great Britain, 2007). PROCEDURE - Explain the procedure to the patient and obtain informed consent. - Prepare the equipment. - Check the prescription chart to ensure that the nebulised drug has been prescribed and is due to be administered. - Check the expiry date of the solution to be nebulised. - Ensure the patient is in a comfortable position, as upright as possible. - If a nebulised bronchodilator is being administered, it is standard practice to obtain a pre and post-administration peak expiratory flow (PEF) reading (Jevon, 2007). - Place the compressor near the patient and plug it into the mains. Clean following local infection control policy and ensure the filter is in place. - Assemble the nebuliser. - Connect the tubing between the nebuliser and the compressor. - Unscrew the top and pour the prescribed solution into the nebuliser chamber. - Ensure the top is firmly reapplied. - Turn on the compressor: the solution to be nebulised should begin to ‘mist’. - Assist the patient to apply the mask or mouthpiece. - Remind the patient that it is important to breath through the mouth and not to talk during the procedure (Porter-Jones, 2000). - Ask the patient to tap on the nebuliser chamber every few minutes - this will help to prevent condensation developing. - Once ‘misting’ has stopped, switch off the compressor and remove the mask or mouthpiece. There is usually a small volume of solution at the bottom of the chamber. - Wash and dry the nebuliser chamber and place the pack in its package for storage. - Offer the patient a drink. - Document that the nebuliser has been administered following local protocols. - In some hospitals it is usual practice to repeat the measurement of PEF. - Wash and dry hands. - If acutely ill patients need to receive their nebuliser using an oxygen supply, connect the nebuliser tubing from the oxygen flow meter to the nebuliser chamber and set the oxygen flow rate to 6-8l/min unless told otherwise (Porter-Jones, 2000). CAUTIONS - Patients with COPD should have nebulisers driven by air (BMA/RPSGB, 2007). - Patients with acute asthma should have nebulisers driven by oxygen (usually 6-8l/min) (BMA/RPSGB, 2007). - If a patient with glaucoma is to receive an anticholinergic drug such as ipratropium bromide, a mouthpiece is preferred as this reduces the leakage of nebulised solution into the eyes (Porter-Jones, 2000). - Compressors should be serviced on a regular basis according to local policy. - Local infection control procedures should be followed to minimise the risk of cross infection. PROFESSIONAL RESPONSIBILITIES This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols. Source
