Welcome to the Specialized Medical Services Respiratory training webinar series!
SMS is your LTC facility single source for oxygen, medical equipment, respiratory care services and supplies nationwide.
This respiratory module is for reference purposes and designed to provide a basic understanding of Aerosol Therapy commonly used in Long
Term Care. It is still important to consult your local respiratory professional and
follow physician orders when applying respiratory treatment.
At the completion of each training module, a short post test will be offered, and with successful completion,
a training certificate recognizing your participation for your records.
Training Objectives
• Understand aerosol and medication delivery systems– How they work
– When to use them
• Know difference between MDI and HHN
• Know how an MDI, Small Volume Nebulizer and Large Volume Nebulizer work
• Know basic set‐up of large volume nebulizer for tracheostomy patient
• Know how to identify patient need for therapy
Aerosol / Nebulizer Therapy
• Aids in bronchial hygiene by:– Restoring and maintaining mucociliary function
– Hydrating dried, retained secretions
– Promoting expectoration of secretions
– Humidifying inspired oxygen, and
– Delivering medications
Small Volume Nebulizer
Large Volume Nebulizer
Large Volume vs. Small VolumeLarge volume nebulizers
– Provide humidity for patients with tracheostomy tube
– High‐output humidification and optional O2
– Requires wall O2 or 50 psi air compressor
Small volume nebulizers– Used to deliver medications
– Given as daily treatments
– Treatments last 10‐15 minutes
– Given via a small compressor and hand‐held nebulizer
Large Volume Nebulizer
Small Volume Nebulizer
Additional Aerosol Devices
Ultrasonic nebulizer– Electrically driven
– Uses high‐frequency vibrations to break surface water into particles
– Creates dense mist that penetrate smaller airways
– Useful for hydrating secretions and inducing cough
Metered Dose Inhaler (MDI) – Administers respiratory medications
– Small, hand‐held pressurized canister
Ultrasonic Nebulizer
Metered Dose Inhaler
What is an MDI?• Helps deliver specific amount of medication to lungs
• Commonly used to treat asthma, COPD, and other respiratory problems.
• Consists of pressurized canister of medication and mouthpiece
• Pressing down on inhaler releases mist of medicine
• Correct use is important to receive right amount of medicine
MDI Spacers
• Important for proper delivery of inhaled drugs
• Holding chamber for medicine
• Attaches to MDI
• Allows propellant in drug to evaporate
• Creates smaller particles, finer mist –medication goes deeper into lungs
• Prevents coughing and yeast infections in mouth
Using an MDI• Fewer side effects • Medicine goes right to the lungs • Takes only 5‐10 minutes to have an effect
3 Techniques for Use• Open mouth technique• Spacer technique• In the mouth technique
Multiple Inhaler Order of Delivery1. Bronchodilators2. Anti‐cholinergic3. Anti‐inflammatory
Common Types of MDIs
Bronchodilator• Widens air passages and eases breathing by relaxing bronchial
smooth muscle when inhaled
Corticosteroid• A class of steroids formulated for use in respiratory tract and
lungs.
• Have anti‐inflammatory effects
• Invaluable in treatment of asthma and other respiratory allergic reactions
Common Types of MDIsAtrovent (Short‐acting bronchodilator)
Aerobid
(Corticosteroid)Combivent (Mixture of ipratropium bromide and albuterol sulfate)
Advair (Contains fluticasone, corticosteroid and salmeterol, bronchodilator
Pulmicort Respules(corticosteroid, uses a Flexhaler, a breath‐actuated dry‐powder inhaler)
Spiriva (A long‐acting bronchodilator, a dry powder inhaler)
Proventil (Short‐acting bronchodilator)
ProAir (Short‐acting bronchodilator)
Ventolin(Short‐acting bronchodilator)
Azmacort (Corticosteroid)
Xopenex (Short‐acting bronchodilator)
Symbicort (Contains budesonide and Formotero
Flovent Diskus (Corticosteroid)
Using an MDI• Remove cap and hold inhaler upright
• Attach MDI to spacer if necessary
• Shake inhaler
• Tilt head back slightly and breathe out
• Use the inhaler in one of these ways
• Press down to release the medicine
• Breathe in slowly for 3 to 5 seconds
• Hold breath for 10 seconds so medicine reaches lungs
• Repeat puffs as prescribed
• Rinse mouth and pharynx after usage if inhaling steroids
• Monitor patient
Cleaning an MDIDaily• Remove your canister before washing
• Rinse in warm running water
• Keep medication opening from becoming crusty
• Let it dry before use
Twice a Week• Wash plastic mouthpiece and spacer with mild dishwashing
soap and warm water
• Rinse and dry well before using
• Keep inhaler cap on to prevent dust and foreign objects
Peak Flowmeters
• Small, hand‐held device
• Measures how fast air comes out of lungs with forceful exhalation
• Can help recognize early signs of worsening asthma,
• Doctors use to decide whento stop or add medications
Small Volume Nebulizer• Used to deliver respiratory meds, such as bronchodilators
• Delivered via small compressor and hand held device
• Mouthpiece recommended instead of mask
• Daily treatments, 10‐15 minutes
• Respiratory solution poured into small med cup
• When gas enters cup, medication is nebulizedRecommended
Common Hand‐Held Bronchodilators
• Albuterol Sulfate
• Atrovent
• Duo Neb
• Formoterol
• Salmeterol
• Xopenex
Small Volume NebulizerTreatment Instructions
• Assemble small volume nebulizer and connect to mini‐compressor
• Add prescribed medication and diluents to nebulizer cup and attach top
• Turn mini‐compressor on
• Instruct patient to breathe in the medication through the mouthpiece
• Watch for the mist to disappear
• Instruct patient to breathe normally – 1 deep breath per minute
• If patient complains of fatigue, stop treatment and resume when patient feels better
Small Volume NebulizerTreatment Instructions
• Medication is gone within 10‐15 min.
• Turn off mini‐compressor
• Reassess patient’s overall tolerance or response to medication
• Remove nebulizer top and shake any remaining liquid into trash container or sink
• Place nebulizer in plastic bag next to mini‐compressor
• Reaffirm instructions and complete documentation
• Wash your hands
Aerosol Face or Tracheostomy Mask•Similar to simple mask design
•Can be applied to tracheostomy opening
•Provides both oxygen and high humidity
•Supplied by large bore tubing
Tracheostomy Aerosol Mist Set Up• When wall oxygen not
available
• Consists of:– 50 psi table‐top air compressor
– Disposable nebulizer circuit with O2 bleed in adapter
– O2 concentrator OR liquid O2 reservoir bleed‐in source
• Flow rate provided determines Fi02
Standard Disposable AerosolCircuit for Tracheostomy
•Circuit comes with prefilled or non filled nebulizer jar
•Oxygen bleed‐in adapter optional when providing > 21% humidity
•Circuit should be changed on regular basis (Q 72 hours recommended)
•Heated humidification option available Prefilled Nebulizer
Bottle w/Fi02 Adapter
Water Drain Bag
TracheostomyMask
02 Connecting Tubingw/ Bleed‐In Adapter
Large Bore Corrugated Tubing
1. Empty nebulizer jar2. Prefilled nebulizer jar3. Heated humidifier option 4. Mask options
2. Prefilled Nebulizer Heater Systems
Large Volume Nebulizer Options
3. Prefilled Nebulizer Bottle w/Fi02 Adapter
1. Empty Nebulizer Jar
4. Mask Options
Aerosol Devices Comparison ChartLong Term Care Application for Adult
Delivery Device Application Patient Notables
Metered Dose InhalerDelivers a dose of medication to your lungs, from
a small, pressurized, hand held canister
• Self administer respiratory meds• Patient needs to be able to coordinate
Breath control and administration techniques
MDI Spacer Aerosol holding chamber device• Improves medication delivery efficiency
Hand Held Nebulizer w/Mouthpiece or Mask
Self administer respiratory treatment and inhale and exhale at own pace
Can be administered with 02 or compressor pump
• Procedure time increases if patient needs caregiver assistance
• Medication distributed unevenly if patient doesn’t breathe properly or when using mask
Large Volume NebulizerProvides for high output humidification by passing air
thru a venturi opening. Moisture can be cool or heated. Delivered with or without oxygen
• Increases risk of bacterial growth in patient circuit
• Condensation collects in large‐bore tubing• Risk of over hydrating patient•Risk of thermal burns with heater device
Ultrasonic Nebulizer Provides for 100% humidity, helps stimulate cough• May cause brocho‐spasm or wheezing in asthmatic patients
Peak Flow MeterHand held device that measures how fast air comes out of the lungs when a patient exhales forcefully.
• Helpful in determining on set of asthma attack
•Patient must be able to follow direction
Monitoring the Effectiveness of Nebulizer Therapy
• O2 Vital sign assessments– Breath Sounds
– Pulse Rate
– Work of Breathing
– Respiratory Rate
– Cough
• Maintain par levels of supplies
• Change delivery devices routinely
Steps to Follow
• Identify patient need
• Verify MD prescription– Aerosol or medication, duration of use, Fi02
• Use appropriate equipment and delivery device
• Monitor efficacy for benefit & continued need
• Follow best practice and safety guidelines
Oxygen Therapy Sample Orders
• Hand Held Nebulizer w/Albuterol QID
• Continuous Aerosol Mist @ 30% Fi02 to Tracheostomy
• Use Spacer Device w/MDI
Session Review• Understand nebulizer delivery devices
– How they work
– When to use them
• How to monitor effectiveness of devices
Informational Resources
• AARC Clinical / Technical References• www.aarc.org
• Manufacturers’ product materialCarefusion www.carefusion.com
Hudson Teleflex www.teleflexmedical.com
Salter Labs www.salterlabs.com