Inhaled medications are commonly prescribed for the treatment of various respiratory conditions, including asthma, chronic obstructive pulmonary disease (COPD), and other pulmonary disorders. These medications are typically inhaled through devices aerosol sprays, mists, or powders that primarily target the respiratory systems but also have systemic effects.
Table of Contents
- What are Inhaled Medications?
- Types of Inhaled Medications
- Indications
- Types of Inhaled Devices
- Steps for Administering Inhaled Medications
- Nursing Considerations
- Sources and References
What are Inhaled Medications?
Inhaled medications are drugs delivered directly to the lungs or respiratory tract via inhalation. They provide localized treatment with minimal systemic side effects. These medications can include bronchodilators to open airways, corticosteroids to reduce inflammation, and other drugs aimed at managing respiratory symptoms.
Types of Inhaled Medications
Inhaled medications can be categorized into several types based on their formulation and purpose in treating respiratory conditions. Here are the main types:
- Bronchodilators. These medications relax the muscles around the airways, helping to open up the air passages and improve airflow.
- Examples:
- Short-acting bronchodilators: Albuterol (salbutamol), levalbuterol.
- Long-acting bronchodilators: Salmeterol, formoterol, tiotropium.
- Examples:
- Corticosteroids (Steroids). These medications reduce inflammation in the airways, helping to prevent and control asthma attacks and other inflammatory lung conditions.
- Examples: Fluticasone, budesonide, beclomethasone.
- Combination Inhalers. These inhalers contain a combination of bronchodilators and corticosteroids in one device for convenience and enhanced treatment effects.
- Examples: Fluticasone/salmeterol, budesonide/formoterol, fluticasone/vilanterol.
- Anticholinergics. These medications help to relax the muscles around the airways and reduce mucus production, improving airflow.
- Examples: Ipratropium bromide, tiotropium.
- Mast Cell Stabilizers. These medications help prevent the release of substances that cause inflammation and allergic reactions in the airways.
- Examples: Cromolyn sodium, nedocromil.
- Antibiotics (in some cases). Antibiotics may be delivered via inhalation to treat respiratory infections such as chronic bronchitis or cystic fibrosis-related infections.
- Examples: Tobramycin inhalation solution, aztreonam inhalation solution.
- Mucolytics. These medications help to break down mucus in the airways, making it easier to cough up and clear from the lungs.
- Examples: Dornase alfa (for cystic fibrosis), hypertonic saline.
Indications
Inhaled medications are indicated for conditions where direct delivery to the lungs or airways is beneficial, such as:
- Asthma
- COPD (Chronic Obstructive Pulmonary Disease)
- Bronchiectasis
- Cystic Fibrosis
- Respiratory infections (e.g., bronchitis)
Types of Inhaled Devices
Inhaled medications may be administered by several methods/devices, each suited to different patient needs and types of medications. Here are the main methods of administering inhaled medications:
1. Nebulizers
Nebulizers utilize a reservoir to hold liquid medication, which is converted into droplets by an aerosol generator. A network of tubes and channels then directs these droplets to the patient through interfaces like a mouthpiece, mask, tent, nasal prongs, or artificial airway suitable for delivering larger doses over a longer periods. Here are the three (3) common types of nebulizers:
- Jet Nebulizers. Jet nebulizers use compressed air to convert liquid medication into a fine mist for inhalation. They are often bulky, require a power source, and can be noisy, but they are effective and commonly used for delivering a wide range of medications.
- Ultrasonic Nebulizers. These nebulizers use ultrasonic waves to produce a mist from the liquid medication. They are quieter and can be more portable than jet nebulizers, but they may not be suitable for all types of medications, especially those that are heat-sensitive.
- Mesh Nebulizers. Mesh nebulizers use a fine mesh to generate a mist from the liquid medication. They are typically small, portable, and silent, making them convenient for travel. However, they can be more expensive and require regular maintenance to keep the mesh clean and functional.
2. Metered-dose inhalers (MDIs)
A metered dose inhaler (MDI) is a small device that delivers a measured amount of medication into the lungs with each spray (puff) during inhalation. MDIs utilize a chemical propellant to dispense the medication dose. This propellant transports the precise amount of medicine into the lungs. The visible spray emitted by the MDI consists of both the propellant and the medication.
The propellants in MDIs, primarily hydrofluoroalkanes (HFAs) like HFA-134a and HFA-227, are used to deliver the medication in a fine mist for inhalation. These environmentally friendly propellants replaced older CFCs and help ensure accurate and efficient medication delivery to the lungs.
3. Dry powder inhalers (DPIs)
DPIs are typically tube- or disk-shaped, equipped with a mouthpiece, and contain a dry powder formulation of one or more medications. Inhalation through a DPI delivers a fine powder directly into the lungs. Unlike metered dose inhalers (MDIs), DPIs demand a forceful inhalation immediately, making it difficult to achieve precise medication dosing. There are 2 types of dry powder inhalers (DPIs):
- Single-Dose DPIs. Single-dose DPIs require the patient to load a new dose of medication before each use. The medication is typically contained in individual capsules or blister packs, which are inserted into the inhaler.
- Examples: HandiHaler, Aerolizer
- Multi-Dose DPIs. Multi-dose DPIs contain multiple doses of medication within the device. The medication is either in a reservoir or in pre-metered doses within the inhaler, allowing for multiple uses before needing a refill or replacement.
- Examples: Diskus, Turbohaler, Ellipta
4. Soft Mist Inhalers
Soft mist inhalers (SMIs), also known as Respimat inhalers, dispense medication in a fine mist that disperses more gradually and lingers longer in the air compared to the aerosol from MDIs. Medication is released by pressing a button on the side of the inhaler while inhaling. SMIs include a built-in dose counter to monitor remaining medication doses; the counter turns red when the inhaler is nearly empty. The device automatically locks once all medication has been dispensed.
Steps for Administering Inhaled Medications
In administering inhaled medications, verify the physician’s order for correct medication and dosage. Perform hand hygiene, document the treatment, and report any unusual events or findings to the physicians.
How to use Nebulizer?
The following are the steps involved in administering nebulization.
Equipment Needed:
- Nebulizer machine (compressor)
- Nebulizer cup and mouthpiece or mask
- Prescribed medication
- Saline solution (if needed)
- Clean water for rinsing
- Towel or tissues
1. Measure the prescribed dose of medication and place it into the nebulizer cup. If necessary, dilute with saline solution as prescribed. Accurate dosing is needed for the effectiveness of the treatment.
2. Connect the mouthpiece or mask to the nebulizer cup and the cup to the compressor. Ensures proper setup for medication delivery.
3. Assist the patient to sit in a comfortable, upright position. Facilitates deep inhalation and lung expansion.
4. Turn on the nebulizer compressor to create the aerosol mist. Activating the machine initiates the process of converting liquid medication into an inhalable mist.
5. Instruct the patient to place the mouthpiece in the mouth or the mask over the nose and mouth, and breathe in and out normally.
Normal breathing allows for continuous and effective delivery of the medication over the duration of the treatment.
6. Continue the treatment until the medication is used up.
The treatment typically lasts 5-10 minutes or until the medication is completely nebulized.
7. Once the medication is finished, turn off the nebulizer machine. Turning off the machine stops the treatment and prepares for equipment disassembly.
8. Disassemble the nebulizer components and rinse them with clean water, allowing them to air dry.
Cleaning the equipment after each use prevents the buildup of medication residue and reduces the risk of infection.
How to use Metered-dose inhalers (MDIs)?
Specific instructions for each inhaler brand are provided by their respective manufacturers; here are some general guidelines.
Equipment Needed:
- Metered-dose inhaler (MDI)
- Spacer (if prescribed)
- Prescribed medication
- Towel or tissues
1. Take off the cap from the mouthpiece of the inhaler.
Removing the cap allows you to access the mouthpiece and prepare the inhaler for priming. It also prevents any obstruction during the priming process.
2. Shake the inhaler vigorously for 5-10 seconds.
Shaking the inhaler mixes the medication properly, ensuring that each dose contains the correct amount of medication. It also prevents the medication from settling at the bottom.
3. Shake the inhaler well for 5-10 seconds.
Shaking the inhaler mixes the medication properly, ensuring an accurate dose is delivered. It also prevents the separation of the medication, which can affect efficacy.
4. Take off the cap from the mouthpiece of the inhaler.
Removing the cap prevents any obstruction of the medication flow. It also maintains the cleanliness of the mouthpiece.
5. Attach the Spacer (if using): If a spacer is prescribed, attach the inhaler to the spacer device.
A spacer aids in better medication delivery to the lungs, especially for those with coordination difficulties. It also reduces medication deposition in the mouth and throat.
6. Have the patient sit or stand in an upright position.
An upright position enhances lung expansion, improving medication delivery. Proper positioning also facilitates easier breathing during inhalation.
7. Ask the patient to exhale completely to empty the lungs.
Exhaling fully creates more space in the lungs for the medication. It also maximizes the effectiveness of the subsequent inhalation.
8. Position the mouthpiece of the inhaler (or spacer) between the patient’s lips and ask to seal the lips tightly around it.
A tight seal around the mouthpiece prevents medication leakage. It also directs the medication into the respiratory tract.
9. Have the patient start to inhale slowly and deeply through the mouth while simultaneously pressing down on the inhaler to release the medication. Coordinating inhalation with actuation ensures the medication is delivered deep into the lungs. Slow, deep breathing optimizes the distribution of the medication within the lungs.
10. Ask the patient to hold breath for about 10 seconds after inhalation.
Holding the breath allows the medication to settle in the airways, enhancing its effectiveness. It also maximizes the absorption of the medication into the lung tissues.
11. Instruct the patient to exhale slowly and gently.
Slow exhalation prevents the rapid expulsion of the medication from the lungs. It also helps the patient maintain calm, controlled breathing.
12. Repeat if necessary: If a second dose is prescribed, wait 30 seconds to 1 minute before repeating the steps.
Waiting between doses allows the first dose to take effect and prepares the lungs for the next dose. It also ensures that the second dose is as effective as the first.
13. Put the cap back on the mouthpiece after use.
Replacing the cap keeps the mouthpiece clean and free from dust and contaminants. It also protects the inhaler from damage.
14. Wipe the mouthpiece with a clean, dry tissue if needed.
Cleaning the mouthpiece maintains hygiene and prevents residue buildup. It also ensures the next dose is not contaminated.
15. Document the Procedure: Record the administration of the MDI in the patient’s medical record, including the medication, dose, time, and any observations.
Accurate documentation provides a record of care, ensuring continuity of treatment. It also facilitates communication among healthcare providers.
How to use Dry Powder Inhalers (DPIs)?
Manufacturer-specific instructions govern the use of each inhaler; here are specific guidelines for reference.
Equipment Needed:
- Dry powder inhaler (DPI)
- Prescribed medication
- Towel or tissues
1. Remove the cap from the inhaler.
Removing the cap allows access to the mouthpiece and prepares the inhaler for use.
2. Follow the manufacturer’s instructions to load the prescribed dose of medication into the inhaler.
Properly loading the dose ensures the correct amount of medication is ready for inhalation.
3. Have the patient sit or stand in an upright position.
An upright position enhances lung expansion, improving medication delivery. Proper positioning facilitates easier breathing during inhalation.
4. Instruct the patient to exhale completely.
Exhaling fully creates more space in the lungs for the medication. It maximizes the effectiveness of the subsequent inhalation.
5. Place the mouthpiece of the inhaler between the patient’s lips and instruct a tight seal around it.
A tight seal around the mouthpiece prevents medication leakage. It directs the medication into the respiratory tract.
6. Have the patient to inhale forcefully and deeply.
A forceful inhalation helps ensure the dry powder reaches the lower airways. Deep breathing maximizes the distribution of the medication within the lungs.
7. Ask the patient to hold breath for about 10 seconds after inhalation.
Holding the breath allows the medication to settle in the airways, enhancing its effectiveness. It maximizes the absorption of the medication into the lung tissues.
8. Instruct the patient to exhale slowly and gently.
Slow exhalation prevents the rapid expulsion of the medication from the lungs. It helps the patient maintain calm, controlled breathing.
9. Replace or put the cap back on the mouthpiece after use.
Replacing the cap keeps the mouthpiece clean and free from dust and contaminants. It protects the inhaler from damage.
10. Wipe the mouthpiece with a clean, dry tissue if needed.
Cleaning the mouthpiece maintains hygiene and prevents residue buildup. It ensures the next dose is not contaminated.
How to use Soft mist inhalers (SMIs)?
Every inhaler manufacturer provides particular instructions for using their device; below are general instructions.
Equipment Needed:
- Soft mist inhaler (SMI)
- Prescribed medication
- Towel or tissues
1. Hold the inhaler upright with one hand, with the cap closed. With the other hand, turn the clear base half a turn to the right until it clicks.
Proper preparation of the inhaler ensures it is ready for accurate medication delivery. The click confirms the inhaler is primed and ready to use.
2. Open the cap from the inhaler.
Opening the cap allows access to the mouthpiece for inhalation. It also indicates the inhaler is ready for use.
3. Breathe out slowly and completely.
Exhaling fully empties the lungs, creating more space for the medication. It helps ensure effective medication delivery during the subsequent inhalation.
4. Place the mouthpiece in the patient’s mouth, holding the inhaler horizontally, pointing toward the back of the patient’s throat.
Proper positioning of the inhaler directs the medication toward the airways. Holding it horizontally ensures the medication is delivered efficiently.
5. Ask the patient to close lips around the mouthpiece.
A tight seal around the mouthpiece prevents medication leakage.
6. Take a slow, deep breath in. While inhaling, press the button on the side of the inhaler and continue inhaling comfortably for three to five seconds.
Coordinating inhalation with pressing the button ensures the medication is delivered deep into the lungs. Slow and deep breathing maximizes medication distribution.
7. When the lungs are full, hold breath for ten seconds to retain the medicine in the lungs.
Holding the breath allows the medication to settle in the airways, enhancing its absorption. It maximizes the effectiveness of the medication.
8. Take the inhaler out of the patient’s mouth and ask the patient to breathe out slowly.
Slow exhalation helps maintain calm, controlled breathing. It prevents the rapid expulsion of the medication from the lungs.
9. Put the cap back on the mouthpiece.
Replacing the cap keeps the mouthpiece clean and free from dust and contaminants. It protects the inhaler when not in use.
Nursing Considerations
Here are the nursing guidelines when administering inhalation devices:
1. If the MDI is being used for the first time, prime the inhaler first.
Prime by first, shake the MDI for five seconds. Press down the canister with the index finger, directing it away from the face to prevent medication from entering the eyes. Repeat shaking and pressing the canister three additional times to administer four doses.
2. Rinse mouth following steroid inhalation.
Rinsing the mouth after using steroids during nebulization helps reduce the risk of developing oral thrush and throat irritation, common side effects associated with steroid inhalation.
3. The patient may use devices such as spacers and chambers to help inhale the aerosol.
The purpose of a spacer during MDI administration is to improve the delivery of medication to the lungs by reducing the need for precise coordination between inhalation and actuation, thereby enhancing the effectiveness of treatment.
4. If a bronchodilator and a steroid are each ordered, administer the bronchodilator first.
Administering the bronchodilator initially widens the airways, allowing the subsequent steroid medication to penetrate deeper into the lungs, thereby enhancing therapeutic effectiveness.
5. Some DPIs require inserting and piercing a capsule containing dry powder medication, while others require rotating a lever to prepare the device for inhalation.
These actions are essential to ensure proper dispersion of the medication for effective delivery to the lungs.
6. Medications in DPIs must be stored in a cool, dry place.
In humid environments, the dry powder medication in a DPI can absorb moisture, causing it to clump together. This clumping can obstruct the device and hinder the medication from being properly inhaled, decreasing its effectiveness.
7. The use of inhaled steroids with patients suffering from COPD may increase the risk of respiratory infection.
Using inhaled corticosteroid inhalers in COPD patients may increase the risk of pneumonia due to their immunosuppressive effects, which can weaken the immune response in the lungs and increase susceptibility to infections like pneumonia.
8. Patients with severe asthma, COPD, or cognitive and dexterity impairments are contraindicated for DPI use due to insufficient inspiratory flow and difficulty using the device.
These patients might struggle to generate the required inhalation force needed to properly draw the medication from a DPI. This can result in ineffective delivery of the medication and decrease therapeutic benefits.
Sources and References
- Anderson, S., Atkins, P., Bäckman, P., Cipolla, D., Clark, A., Daviskas, E., … & Weers, J. (2022). Inhaled medicines: past, present, and future. Pharmacological Reviews, 74(1), 48-118.
- Komalla, V., Wong, C. Y. J., Sibum, I., Muellinger, B., Nijdam, W., Chaugule, V., … & Traini, D. (2023). Advances in soft mist inhalers. Expert Opinion on Drug Delivery, 20(8), 1055-1070.
- Lavorini, F., Janson, C., Braido, F., Stratelis, G., & Løkke, A. (2019). What to consider before prescribing inhaled medications: a pragmatic approach for evaluating the current inhaler landscape. Therapeutic advances in respiratory disease.
- Muralidharan, P., Hayes Jr, D., & Mansour, H. M. (2015). Dry powder inhalers in COPD, lung inflammation and pulmonary infections. Expert opinion on drug delivery, 12(6), 947-962.
- Sorino, C., Negri, S., Spanevello, A., Visca, D., & Scichilone, N. (2020). Inhalation therapy devices for the treatment of obstructive lung diseases: the history of inhalers towards the ideal inhaler. European Journal of internal medicine, 75, 15-18.
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