Trust Guideline

NEBULISER GUIDELINES
All healthcare professionals must exercise their own professional judgement when using guidelines. However any decision to vary from the guideline should be documented in the patient records to include the reason for variance and the subsequent action taken.

Lead Clinician(s): Lead Director

Helen Designation Specialist Respiratory NurseAbdullah COPD Sandra Rote

Ratified by: Date of Ratification This Policy should not be used after end of: Links into Healthcare Standard: Impact Analysis (Race Equality) Impact Analysis (Mental Capacity Act)

Quality and Safety Committee 29th January 2008 January 2010

COPD Associate Director of Nursing Circulated to the following individuals for comments Name Designation Sue Lunec PCT Pharmacist Maria Wilday Matron/Manager POWCH Carole Clive Infection Control Nurse Melanie Hart PPF Practice Nursing/Community Matron Alison Glover District Nurse Gladys Davies District Nurse Cathy McCleod Community Physiotherapist Nigel Window Specialist Respiratory Nurse Sue Bosworth Primary Care Services Development Manager Lesley Way Patient Safety Manager Nebuliser Guidelines – WPCT Page 2 of 11 .CONTRIBUTION LIST Key individuals involved in developing the document Name Helen Abdullah Vicky Preece Designation Specialist Respiratory Nurse .

.. 6 8..................................................0 Storage .......................................................................................................... 9 14..................................................................... 10 BIBLIOGRAPHY ..............................0 Patients Covered .............................. 10 15.......................................................................................................................................................0 Hazards / Complications ..................................0 Residual Volume ..................... 8 10.. 5 6.0 Delivery Gas ...............0 Competency Required ........................................ 11 Nebuliser Guidelines – WPCT Page 3 of 11 ............................................................. 7 9......................................................................................................................... 9 12..............................................0 Fill Volume ........................0 Special Precautions ..........................0 Infection Control Issues..................................................................................0 Nebulisation Time .............................................................................................................................................. 9 13......................................... 5 4................................ 9 11.................. 4 2.......................................0 Responsibility and Accountability ...............................................................................0 Introduction ..........................0 Safety.........Contents 1..................... 5 5..................................................................................... 10 References.......................................... 4 3..............0 Scope of Guidelines ................................................................................ 5 7...................................................0 The Procedure ..............................

2.0 Scope of Guidelines These guidelines cover all staff working on behalf of Worcestershire Primary Care Trust who administer nebulised therapy. Nebuliser therapy is also indicated to deliver prophylactic medication such as steroids for patients unable to use other inhalation devices (particularly a young child). The purpose of these guidelines is to: Provide a framework for standardised nebuliser administration.0 Introduction “The aim of nebuliser treatment is to deliver a therapeutic dose of the drug as an aerosol in the form of respirable particles within a fairly short period of time” (British Thoracic Society 1997 (B T S). Please note nebulisers and compressors are not available on the NHS. These guidelines cross reference with: • • The PCT’s Medicine Policy The Worcestershire Support Services Agency Infection Control Policy and Procedures Nebuliser Guidelines – WPCT Page 4 of 11 . Currie & Douglas 2007) “Nebulisers are useful when large doses of inhaled drugs are needed when patients are too ill or otherwise unable to use handheld inhalers and when drugs are not available in that format for example antibiotics” (B T S 1997) The commonest indication for nebulised therapy is the emergency treatment of acute asthma and exacerbations of chronic obstructive pulmonary disease. However it can also be used long term to deliver regular higher doses of bronchodilators that have shown to be beneficial in some patients. to deliver antibiotics such as colistin in cystic fibrosis. knowledge and evidence of good practice necessary for them to safely administer nebulised therapies.1. and budesonide for a child with sever croup. Provide healthcare professionals with support.

5.0 Patients Covered These guidelines apply to all patients treated as inpatients.0 Hazards / Complications Adverse side effects of nebulisation are usually considered to be drug related. 4. Nebulised medications must be administered in accordance with the Worcestershire PCT Trust Medicines Policy.0 Competency Required These guidelines apply to all healthcare professionals who undertake administration of nebulised therapies. outpatients and in their home environments. However. They are reminded that they should at all times adhere to: • • The Nursing and Midwifery Council Code of Professional Conduct (2002) The Chartered Society of Physiotherapists’ Rules of Professional Conduct (2002) NB. 6. These include: • • • • • • • Giddiness Tremor Nausea Palpitations Dry mouth Wheeziness Bronchospasm Nebuliser Guidelines – WPCT Page 5 of 11 . is accountable for the delegated task.0 Responsibility and Accountability All healthcare professionals who administer nebulised therapies should be aware of the contents of these guidelines. The Trust’s Medicines Policy supports the health care assistants working in the community setting to administer nebulised medicines.3. it must be remembered that the registered health care professional who delegates this task to a health care assistant.

acidic or contain certain preservatives can cause bronchoconstriction. 7. The driving gas (hospital use) should be set at the appropriate flow rate. Medications should be given in accordance with the prescription or Patient Group Direction (PGD) via the nebuliser chamber. The appropriate equipment for delivery of the nebulised therapy should be collected on a clean surface. Patients should be advised to relax and breathe normally The treatment is nearly finished when the nebuliser begins to “spit”. Nebulised solutions. The compressor should be placed on a hard safe surface (not the floor) when in use.0) (Jevon 2007) Nebuliser Guidelines – WPCT Page 6 of 11 . The next time the nebuliser begins to “spit” the treatment is complete. Following inhalation via a facemask it is advisable to wash the face to prevent skin irritation.0 The Procedure • • • • • • • The patient should be sat in a comfortable upright position to enable the nebuliser to function optimally. Adverse effects can be monitored by measuring spirometry or peak flow before and after an initial dose of the drug.• • Constipation Irritable cough These side effects are usually easily remedied and the patient can be reassured by observing their breathing pattern and consulting the prescribing physician (Cockcroft 1989). non-isotonic. • • Once the nebuliser is complete the driving gas or compressor should be switched off. (see section 13. It is also advisable following steroid inhalation to rinse out the mouth to avoid possible oral candidiasis (Dodd 1996). which are cold. At this point the patient or carer should gently tap the side of the nebuliser a few times. The nebuliser should either be disposed of or cleaned in the recommended manner.

If nebulising at home.g. • Steroids The special precautions used for nebulised antibiotics also apply to nebulised steroids. Where the patient is too ill to cope with a mouthpiece eye protection e.0 Special Precautions • Mask or Mouthpiece Bronchodilator responses are the same whether a mask or mouthpiece is used. Facemasks should be tight fitting and patients should be advised to breathe with an open mouth (B T S 1997) • Ipratroprium Bromide The health care professional must be aware that there is a potential risk of glaucoma if ipratroprium bromide (especially when mixed with salbutamol) comes into contact with the eyes. Filters should be allowed to dry thoroughly between uses. glasses or goggles should be provided (Dodd 1996). advice from the pharmacist or respiratory team should be sought. patients may nebulise antibiotics alone in a separate room with an open window and closed door without using a filter system. • Other Drugs Where nebulisation of other drugs is considered e. Nebuliser Guidelines – WPCT Page 7 of 11 . A mouthpiece should also be used to prevent topical deposition on the skin. The choice should therefore depend upon patient preference and convenience.8. Wherever possible a mouthpiece should be used in preference to a facemask. However the use of a venting system or filter is preferable (B T S 1997). Therefore it is advocated that the patient rinses their mouth out or cleans their teeth following nebulisation. One further precaution is the prevention of oral candidiasis. lignocaine.g. Anti-cholinergic bronchodilators must also be used with caution in patients with benign prostatic hyperplasia and bladder outflow obstruction (B N F 2007) • Antibiotics When nebulising antibiotics the nebuliser set should be fitted with a filter system.

if required. it is preferable that patients have air driven nebulisers and are given supplementary oxygen concurrently by nasal cannulae. Nebuliser Guidelines – WPCT Page 8 of 11 . Air should always be used where there is a risk of carbon dioxide retention by patients with chronic obstructive airways disease.Piped oxygen can be used for patients suffering with acute asthma at a rate of 6 – 8 litres per minute unless otherwise stated on the packaging of the nebuliser equipment being used. therefore an electrical compressor is required. However. Consequently the dose of a bronchodilator given by nebulisation is much higher than by inhaler. Compressed air (via piped system in hospital) or compressor (in hospital or community) is the most commonly used driving gas.0 Delivery Gas A gas flow of 6 – 8 litres per minute is required for jet nebulisers to provide 50% of the particles at a diameter of less than 5 microns.• Dosage The proportion of a nebuliser solution that reaches the lungs can be as high as 30% but more frequently is close to 10% or less.Most domiciliary oxygen cylinders are only capable of delivering 4 litres per minute and are inappropriate for driving nebulised medications (Evans 1990). These are normally supplied in consultation with the home oxygen contractor and an additional home oxygen order should be completed. The home oxygen contractor can supply cylinders that deliver greater flow rates via a multi-flow valve. 9. Community use. Hospital use. (Esmond 2001). This is the size required for adequate deposition in the distal airways. Patients should be advised of this. (Esmond 2001) In accordance with the PCT Medicine Policy the driving gas must be specified as part of the prescription.

All administration equipment except the tubing should be washed after each use with general purpose detergent and warm water. since the fill volume required for drug delivery can then be determined.5 – 2. They should then be thoroughly dried using a soft towel.5 ml. (Everard et al 1994) 13. For residual volumes of more than 1 ml. (Esmond 2001) 11. (Barnes 1987) All nebuliser administration sets are single patient use only. nebulisation time should be 5 – 10 minutes. the fill volume need not be more than 2. mouthpieces and tubing can be re-used for the same patient unless specifically stated on the packaging. Most chambers require 2 – 4. Ensure all the equipment is dry before Nebuliser Guidelines – WPCT Page 9 of 11 . Tapping the nebuliser towards the end of the nebulisation time has shown to increase the total volume of drug nebulised.0 Infection Control Issues Bacterial contamination is a frequent finding in compressors and may be the source of pathogens. Longer nebulisation time will decrease patient adherence to treatment (Smith 1986).0 Nebulisation Time For bronchodilators. the drug chamber must be filled with a minimum volume of drug to enable a sufficient dose to be given.0 Residual Volume This is the volume of the solution left in the chamber when nebulisation is complete.5 ml depending on the residual volume. It is important to know this volume.0 Fill Volume In order to maximise the efficiency of the nebuliser. (Esmond 2001) 12. Most nebulisers have a residual volume of 0. Other drugs may require a longer time for nebulisation to be completed in order to achieve a higher drug output. The tubing should be attached to the gas delivery device and turned on for a few seconds. a fill volume of at least 4 ml is required. Low residual volumes allow a smaller fill volume.10.5 ml. which will remove any dampness from inside the tubing. Nebuliser masks. For residual volumes of less than 1 ml.

COMBER P. GORE B P.42 Nebuliser Guidelines – WPCT Page 10 of 11 . in: Currie G (ed) ABC of COPD: Oxford: Blackwell DEPARTMENT OF HEALTH (1991): Safety of electrical medical and laboratory equipment: Safety Action Bulletin No. (1989): Importance of evaporative water losses during standardised nebulised inhalation provocation tests: Chest: 96 pp 505 – 508 CURRIE G. ROLLO C. BELL E. (1996): Nebuliser therapy: what nurses patients need to know: Nursing Standard: 10 (31): April: pp 39 .putting it in a designated container ready for its next use. 74: SAB (91): 57: Department of Health: London DODD M. (1987): Bacterial contamination of home nebulisers: British Medical Journal: 295: pp 812 BRITISH NATIONAL FORMULARY (2007): No 54 September 2007: Pharmaceutical Press: Oxon BRITISH THORACIC SOCIETY (1997): Nebuliser Therapy Guidelines: Thorax: 52 suppl 2: S4 – 24 CHARTERED SOCIETY OF PHYSIOTHERAPISTS (2002): Rules of Professional Conduct COCKCROFT D W. Records of the dates of safety checks of compressors and detachable leads are mandatory (DOH 1991). the frequency of which is determined at local level. DOUGLAS J (2007): Oxygen and inhalers. 14. MURPHY D. 15. HURST T S. HOLGATE S T. This procedure needs to be carried out weekly. The compressor when unplugged will need to be wiped over with a damp cloth and general-purpose detergent. References BARNES K L. For hospital patients this container should be clearly labelled with the patient’s name.0 Safety It is a legal requirement that compressors have an electrical safety check at regular intervals.0 Storage When not in use the compressor should be stored clean and dry without nebuliser equipment attached.

WORCESTERSHIRE PRIMARY CARE TRUST MEDICINE POLICY ( 2007 ) SMITH G. (1990): Dangers of Nebulisers: Lancet: 6 pp 336 EVERARD M L. (1994): Is tapping jet nebulisers worthwhile?: Archives of Diseases in Childhood: 70 pp 538 – 539 JEAVON P.ESMOND G. (2007): Respiratory Procedures part 3 use of a nebuliser: Nursing Times vol103 No 34 Aug 21 pp 24-25 NURSING AND MIDWIFERY COUNCIL (2004): the NMC Code of professional conduct: standards for conduct. EVANS M. performance and ethics. (1986): A patients view of cystic fibrosis: Journal of Adolescent Health Care: 7 pp134 – 138 BIBLIOGRAPHY WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST (2002): The Clinical Guideline for the use of Nebulisers: WHAT-RES-002 Nebuliser Guidelines – WPCT Page 11 of 11 . (2001): Respiratory Nursing: Bailliere Tindall: London EVANS D H. MILNER A D.

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