14.4: Administering Inhaled Medications

Learning Objectives

By the end of this section, you will be able to:

• Describe the different forms of inhaled medications
• Understand the categories of inhaled medications
• Verbalize procedural steps for administering inhaled medications

Medications administered through inhalation are dispersed via an aerosol spray, mist, or powder that patients inhale into their airways. Although the primary effect of inhaled medications is respiratory, there are likely to be systemic effects as well. Inhaled medications are absorbed easily by the lungs because of the large surface area of the lungs with high blood flow. Therefore, inhaled medications work faster than oral medications. Medications may be inhaled into the respiratory tract to reduce inflammation in the airways, open the lungs, and treat a variety of respiratory illnesses.

Forms of Inhaled Medications

Inhaled medications may be administered by nebulizers or hand atomizers. Although both forms of inhaled medications are used to deliver medications into the lungs to treat respiratory conditions, the selected form may depend on several factors. Hand atomizers tend to be smaller and more portable than nebulizers; however, nebulizers may be the preferred option for patients who experience difficulty in coordinating and controlling their breaths.

Nebulizer

A nebulizer is a small electric or battery-powered machine that delivers a fine mist of liquid medications (Figure 14.17). Oxygen or compressed air is used to transfer the medication from the nebulizer and into the lungs via a face mask or mouthpiece. The oxygen or compressed air moves the particles, so the patient may be instructed to breathe normally during nebulized medication administration. To reduce the risk of bacteria, nebulizers should be cleaned after each use, disinfected at least once per week, and left out to air-dry after cleaning. Medications, such as bronchodilators (medication that relaxes the muscles in the lungs and widens the airway) and antibiotics, may be administered via a nebulizer. Steroids cannot be administered via a nebulizer and require an inhaler. When administering medications via nebulizers, monitor the patient’s heart rate throughout the treatment because these medications may cause tachycardia or other cardiac effects, such as palpitations or irregular heart rhythms.

Figure 14.17: This mannequin is wearing a face mask with an attached nebulizer, which is used to deliver inhaled medications. (credit: British Columbia Institute of Technology, CC BY 4.0)

Clinical Safety and Procedures (QSEN): QSEN Competency: Administering a Nebulizer Treatment

See the competency checklist for Administering a Nebulizer Treatment. You can find the checklists on the Student resources tab of your book page on openstax.org.

Life-Stage Context: Administering Nebulizers to Children and Older Adults

Nebulizers are often recommended for administering inhalation medications to children and older adults because nebulizers do not require coordination of breathing and administration efforts. Although typically a mouthpiece is more efficient for delivering nebulized medications, a face mask should be used with young children and older adults. Face masks are easier to use with these populations because these patients often have difficulty keeping nebulizer mouthpieces in their mouths. It is important to ensure the patient keeps the mask on for the duration of the treatment. Giving the patient something to do, such as reading a book, playing with a toy, or reading the newspaper, can be very beneficial for keeping children and older adults occupied and helping them remain still throughout the nebulizer treatment.

Though nebulizers take time to set up, they can be more effective to use during asthma attacks because the medication is pressurized into the lungs versus requiring a deep breath to inhale the medication into the lungs. Nebulizers may also be easier to use with young children because instructions for teaching the child how to breathe during the medication administration are not required. Another benefit of nebulizers is that multiple medications may be delivered simultaneously. Although nebulizers can be very beneficial, they are not as easy as an inhaler to transport, often require a power source, and take longer to administer the medication than when administered through an inhaler.

Patient Conversations: Educating a Child on Nebulizers

Nurse: Good morning. My name is Nurse Sarah and I’m here to help you with your nebulizer treatment today. What’s your name?

Child: Hi, Nurse Sarah. I’m Emily.

Nurse: It is nice to meet you, Emily. How are you feeling today?

Child: I’m okay, but my chest feels a little tight.

Nurse: I’m sorry to hear that. It’s great that you’re here so we can help you feel better. Do you know what a nebulizer is, Emily?

Child: Yeah, my mom told me it’s a machine that will help me breathe better.

Nurse: That’s right! It’s like magic mist that helps open up your airways. It’s a bit noisy, but it’s not scary. Now, let’s get everything ready. I am going to turn on the machine and it will turn the medicine into a mist that you’ll breathe in through this mask.

Child: Okay, but will it taste bad?

Nurse: It might have a slightly funny taste, but it’s not too bad. You can think of it as a special potion that will help you breathe better. Plus, you can drink some water afterward if you like.

Child: Okay, I can do that.

Nurse: I am going to put the mask on you, and you just need to sit back, relax, and take slow, deep breaths. You can watch your favorite show, read a book, or even close your eyes and imagine a fun adventure.

Child: Can I pretend I’m a dragon breathing fire?

Nurse: Absolutely! That sounds like a fantastic adventure. You can be a dragon while you take your treatment.

Scenario follow-up: Emily puts on the mask, and Nurse Sarah starts the nebulizer machine. Emily continues her nebulizer treatment, imagining herself as a dragon, while Nurse Sarah keeps an eye on her and offers reassurance throughout the process.

Hand Atomizer

A hand atomizer (inhaler) is a pocket-sized device that delivers medications into the lungs without the use of electricity. There are three main types of hand atomizers: metered-dose inhalers, dry powdered inhalers, and soft-mist inhalers. To prevent bacterial growth, inhalers should be cleaned frequently. Most inhalers track the number of doses administered, allowing for medication refills to be obtained before running out of the medication.

Metered-Dose Inhaler (MDI)

A metered-dose inhaler (MDI) creates an aerosolized mist of medication that is inhaled through the mouth and into the lungs (Figure 14.18). The canister is attached to a mouthpiece and the medication is administered into the lungs by pressing on the canister while coordinating breathing efforts. Medication waste is common with MDIs because mist particles stick to the tongue or aerosolize in the air. MDIs may be used for steroids, bronchodilators, and combination medications. Examples of MDIs include albuterol inhalation (ProAir HFA) and fluticasone inhalation (Flovent).

Figure 14.18: Metered-dose inhalers (MDIs) consist of a medication canister, plastic holder, and mouthpiece cap. Some MDIs also include a counter that indicates the number of doses remaining. (credit: donated by Carol Clarkson)

A spacer may be used to prevent waste of medication and allow for the full dose to be administered (Figure 14.19). A spacer is a clear tube that fits between the inhaler and the mouthpiece. After the medication is released from the inhaler, it moves into the spacer, which allows the patient to inhale the medication more slowly and with control. The spacer must be cleaned frequently to prevent bacterial growth.

Figure 14.19: A spacer allows for more controlled administration of medication from MDIs. (credit: donated by Carol Clarkson)

Dry Powder Inhalers (DPI)

A dry powder inhaler (DPI) provides dry powder medications that are inhaled through a device in the mouth and into the lungs (Figure 14.20). Unlike MDIs, DPIs use an inward breath to move the medications into the lungs instead of a propellant. After the dose is activated, a quick inhale activates the medication and moves it into the lungs. Typically, DPIs are easy to use, do not require a spacer, and do not require the same coordinated efforts in breathing and operating the device as MDIs. Unlike MDIs, DPIs require more forceful breaths, are more difficult to receive an exact dose of medication, and can be affected by humidity. Examples of DPI mediations include budesonide inhalation suspension (Pulmicort) and fluticasone-salmeterol inhalation powder (Advair Diskus). Patients should be instructed to rinse their mouth, spitting out the rinse, after use of a DPI to reduce the risk of oral thrush (fungal infection), local side effects (such as throat irritation, dry mouth, and hoarseness), and to prevent unintentional swallowing of the medication particles.

Figure 14.20: The dry powder is contained in a capsule that is placed inside the DPI. The DPI is closed and the capsule is broken open inside so the user can inhale the powder. (CC BY 4.0; Rice University & OpenStax)

Soft-Mist Inhaler

A soft-mist inhaler is a handheld device that turns liquid medications into a mist cloud that can then be inhaled without a propellant. The medication contains more particles and leaves the inhaler more slowly than with MDIs or DPIs; therefore, more of the medication enters the lungs and a lower dose of the medication may be used. This type of inhaler does not require coordinated breathing efforts or a spacer. An example of soft-mist inhaler medication is tiotropium/olodaterol (Stiolto Respimat).

Categories of Inhaled Medications

There are several categories of inhaled medications, including bronchodilators, steroids, antibiotics, and dornase alfa, an inhaled medication made of synthetic proteins used to treat cystic fibrosis (CF). The category of inhaled medication prescribed is dependent on factors such as the patient’s condition, severity of symptoms, and potential side effects. It is important for the nurse to understand the various categories of inhaled medications, their indications, how they work, and potential side effects.

Bronchodilators

A bronchodilator is a medication that relaxes the muscles in the lungs and widens the airways. Bronchodilators are used to treat long-term conditions (e.g., asthma, chronic obstructive pulmonary disease [COPD]) in which the airways become narrower and more inflamed. Bronchodilators may be short-acting (i.e., unexpected attacks of breathlessness) or long-acting (i.e., to help control breathlessness) in asthma and COPD. Potential side effects of bronchodilators include trembling in the hands, headaches, dry mouth, heart palpitations, muscle cramps, cough, diarrhea, or nausea and vomiting.

The most widely used bronchodilators for inhalation are beta-2 agonists and anticholinergics. Beta-2 agonists stimulate beta-2 receptors in the muscles that line the airways, causing them to relax and dilate. These medications should be used with caution for patients that have hyperthyroidism, cardiovascular disease, arrhythmias, hypertension, or diabetes, as the symptoms of these conditions may worsen. For example, bronchodilators can stimulate the sympathetic nervous system, which may lead to increased heart rate, increased blood pressure, chest pain, and an irregular heart rate. They can also stimulate the liver to release glucose, which increases the blood glucose levels. Examples of beta-2 agonists include salbutamol (Ventolin) and vilanterol (Breo Ellipta). Anticholinergics dilate the airways by blocking the cholinergic nerves. These medications should be used with caution for patients who have benign prostatic hyperplasia (BPH), bladder obstruction, or glaucoma. For example, anticholinergics can worsen the symptoms of BPH and bladder obstruction by relaxing the bladder muscles, causing urinary retention. These medications can also cause the pupil to dilate, thereby increasing intraocular pressure and worsening glaucoma. Examples of anticholinergics include ipratropium inhalation (Atrovent) and glycopyrronium (Qbrexza).

Steroids

A steroid is an anti-inflammatory medication. A corticosteroid is a medicine that reduces inflammation and prevents flare-ups of respiratory conditions. Corticosteroids are the gold standard treatment for asthma and may be taken in combination with bronchodilators to help keep the airways open and enhance the effectiveness of the corticosteroids. People taking inhaled steroid medications should be instructed to brush their teeth or rinse their mouth with water after administering the medication to decrease the risk of fungal infections. It is important they do not swallow the rinse water because doing so may cause a fungal infection in the throat. Examples of steroid inhalation medications include beclomethasone inhalation (Beclovent) and fluticasone inhalation (Flovent). Potential side effects of steroid inhalers include a sore mouth or throat, hoarse voice, cough, or oral thrush.

Antibiotics

Antibiotics may be warranted for patients with chronic respiratory diseases, such as CF, non-CF bronchiectasis (a chronic condition where the lung walls are thickened due to inflammation and infection), and ventilator-associated pneumonia. Inhaled antibiotics have the potential to deliver higher concentrations of medications without the systemic effects of oral or parenteral administration. Examples of inhaled antibiotics include aztreonam (Azactam) and tobramycin inhalation powder (Tobi Podhaler). Potential side effects of inhaled antibiotics include new or worsening breathing problems, ringing in the ears, hoarse voice, dizziness or balance problems, muscle weakness, or kidney problems.

Dornase alfa

An inhaled medication consisting of a synthetic protein that breaks down excess DNA in the pulmonary secretions of people with CF is known as dornase alfa (Pulmozyme). They help to improve the lung function and lower the risk of infection by thinning the mucus in the airways. Dornase alfa is inhaled via a nebulizing device that creates a mist from the liquid medication. It must be kept in the refrigerator, protected from sunlight, and discarded after it is opened. This medication is stored in foil pouches to protect it from sunlight and should not be left at room temperature for longer than twenty-four hours. No other medications should be mixed with dornase alfa during the nebulizing treatment. Potential side effects of dornase alfa include loss of voice, throat discomfort, red or watery eyes, rash, runny nose, shortness of breath, fever, chest pain, indigestion, or diminished lung function.

Procedural Steps for Administering Inhaled Medications

Regardless of the type of inhaled medication, the nurse should perform hand hygiene, apply gloves, and perform the same rights of medication administration as is completed with other types of medications. Perform and document a respiratory assessment, including respiratory rate, oxygen saturation level, heart rate, lung sounds, and respiratory effort.

To administer nebulizers, pour the liquid medication into the medication cup of the nebulizer. Sit the patient in high Fowler’s position with the head of the bed elevated between 60 and 90 degrees, if possible. Attach the nebulizer to an oxygen set with a flow rate of 6 to 10 L/min, based on the manufacturer’s guidelines. Check for misting to ensure the equipment is working properly. Attach the top end of the tubing to the nebulizer mask. Instruct the patient to take slow, deep breaths through their mouth, pausing for two to three seconds before each exhale. If the patient is dyspneic, encourage them to hold their breath every fourth or fifth breath for five to ten seconds. Instruct the patient to continue the breathing pattern until the medication has been fully administered, as evidenced by no visible misting. Nebulized medications typically take ten to fifteen minutes to administer. After the treatment is completed, turn off the oxygen flowmeter, unless the patient is receiving oxygen therapy, and disconnect the nebulizer. After administration, encourage the patient to cough and breathe deeply and perform oral care. The nurse should then re-evaluate the patient’s respiratory system to include respiratory effort. Perform hand hygiene and document administration of the medication as well as the patient’s tolerance of the medication and procedure.

Link to Learning

Watch this demonstrational video about nebulized medications to learn how to administer them.

To administer an MDI, shake the inhaler and attach the spacer, if applicable. Have the patient place the mouthpiece of the inhaler or spacer between their lips, while tightly closing their lips around it. If a spacer is not used, the inhaler may be held 1 to 2 in (2.5 to 5 cm) from the mouth. Instruct the patient to breathe out and then press the inhaler down at the same time the patient is breathing in. Instruct the patient to keep breathing in, slowly, for three to five seconds and then hold their breath for five to ten seconds to get the medication into the airways. A slow inhale is required to prevent the medication from hitting the back of the throat instead of moving into the lungs. Slowly breathe out and repeat if more than one puff is required. When administering corticosteroids, instruct the patient to rinse their mouth to prevent fungal infections. Instruct the patient not to swallow the rinse water to prevent fungal infections in the back of the throat. Perform hand hygiene and document administration of the medication as well as the patient’s tolerance of the medication and procedure.

Link to Learning

Watch this demonstrational video about metered-dose inhaler medications to learn how to administer them.

Clinical Judgment Measurement Model: Take Action: Implementing a Spacer

The nurse is caring for an older patient who is taking a metered-dose inhaler. The patient will be discharged with the inhaler, so the nurse allows the patient to self-administer the medication under nurse supervision. The nurse notices the patient pressing down on the canister and then pausing before inhaling. The nurse recognizes the cues that the patient is using an incorrect technique. The nurse analyzes the cues, understanding that the patient should begin breathing in while simultaneously pressing down on the medication canister. The nurse prioritizes the hypotheses that the delay in breathing is resulting in medication waste and the patient is not receiving the full dose of the medication. The nurse generates a solution by recognizing that the patient may benefit from using a spacer and takes action by contacting the respiratory department to obtain a spacer that can be used with the next administration of the medication.

To administer dry-powder inhalers, remove or rotate the cap of the inhaler. Load the medication, if applicable, and press down on the lever per manufacturer’s guidelines to activate the medication. Instruct the patient to turn their head away from the device and breath all the way out. Place the mouthpiece into the mouth and close their lips around it. Breathe in deeply for a few seconds. Take the device out of the mouth and instruct the patient to hold their breath for up to ten seconds before slowly breathing out. Instruct the patient to rinse their mouth with water or brush their teeth, ensuring they do not swallow the rinse water. Perform hand hygiene and document administration of the medication as well as the patient’s tolerance of the medication and procedure.

To administer soft-mist inhalers, prepare the device according to the manufacturer’s instructions, open the cap, and instruct the patient to breathe out slowly and fully. The nurse instructs the patient to place the mouthpiece in the mouth, using caution not to cover the air vents on the sides of the device. Press the dose release button while the patient slowly inhales the mist. Instruct the patient to hold their breath for ten seconds and repeat, as prescribed. Perform hand hygiene and document administration of the medication as well as the patient’s tolerance of the medication and procedure.

Order of Inhaled Medications

When administering multiple inhaled medications, the order of administration matters. If the patient is ordered a bronchodilator, the bronchodilator should be administered before any other inhaled medication, which relaxes and opens the airway and allows the other medications to work more effectively. Next, administer dornase alfa, if ordered, which breaks up and thins the mucus. After encouraging the patient to cough and breathe deeply to clear the mucus, the antibiotic is the next medication to be inhaled, which kills the bacteria in the lungs. Steroids are administered last, when the lungs are the most cleared, which reduces the swelling that may have been caused by the mucus and infection.