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Document derivation /
evidence base:
Review Date 2018
Lead Executive Director of Nursing
Author/Lead Manager Julie Morgan Respiratory Specialist Nurse
Further
Guidance/Information
Distribution: Ward Sisters/Charge Nurses, PDMs, Clinical
Leads, Matrons, Nursing Practice Guidelines
Group (includes University of Nottingham
representative), Clinical Quality, Risk and
Safety Manager, Trust Intranet.
Add any extra groups/organisations to whom guideline has
been circulated
This guideline has been registered with the Trust. However, clinical
guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is
advised when using the guidelines after the review date.
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Nottingham University Hospitals NHS Trust
CLINICAL GUIDELINES
INTRODUCTION
INDICATIONS
CONTRAINDICATIONS
A known sensitivity to the drug being nebulised. See the most up to date
edition of the British National Formulary for further information on specific
drugs.
Nebulisers just before meals may spoil an already small appetite, but
other patients who are severely breathless may need the bronchodilation
to give them breath to eat.
HAZARDS/CAUTIONS
Oxygen should be used with caution in patients with COPD as some may
be vulnerable to episodes of hypercapnic respiratory failure. For this
reason oxygen must always be prescribed by a member of the medical
staff (BTS, 2011).
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Antimuscarinic bronchodilators such as ipratropium bromide
cause/exacerbate glaucoma, particularly when given with nebulised
salbutamol (and possibly other 2 agonists) (BNF, 2011). Therefore, a
mouthpiece should be used.
EQUIPMENT
Straight tubing must be used in order to maintain the correct flow and to
avoid disconnection. Bubble tubing should never be used, as it does not
maintain a constant flow rate. Tubing is also single patient use only.
Prescription chart
Prescribed medication
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PRINCIPLES OF CARE
PRINCIPLE RATIONALE
1 Check prescription chart according Drug is given as prescribed and the
to the local drug administration risk of drug errors if administered.
policy to ascertain type of medication
and correct dosage needed. Check
drug and expiry date. Undertake
positive patient identification in Ensures correct patient receives
accordance with Trust policy the medication prescribed.
2 Assist the patient into a comfortable To minimise dyspnoea and to allow
position, preferably sitting upright, maximum lung expansion in order
and advise to take normal steady to ensure medication reaches the
breaths (tidal breathing). bronchioles.
Fit the mask to the patient or ensure Ensures that patient receives the
the mouthpiece is ready for use prior complete dose and that staff are
to starting the nebuliser not unduly exposed to the
nebulised medication
6 Switch compressor on or To deliver the drug.
compressed air flow to 6 8 litres
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be allowed to air dry on a paper washing chambers and pouring the
towel effluent down sinks which has a risk
of aerosolising any pseudomonas.
CARE OF EQUIPMENT
When the compressor unit is switched off, wipe it with an antimicrobial
swab and store it away. The compressor should not be stored on the floor
or near water hazards. Compressors must be regularly serviced every six
months by MESU. If cylinder oxygen is used, ensure the cylinder is turned
off using the key after use to prevent leakage.
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REFERENCES
British Thoracic Society (1997) Current best practice for nebuliser treatment.
Thorax Supplement 2. 52.
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Appendix 1
Bronchodilators:
2 agonists e.g. salbutamol and terbutaline
Antimuscarinics (anticholinergics) e.g. ipratopium bromide
Combination therapy e.g. Combivent (salbutamol and ipratropium
bromide).
Corticosteroids:
Budesonide and Fluticasone (see appendix 2)
Antibiotics:
Colistin (Colomycin) (see appendix 3)
Ribavirin (specialist areas only)
Pentamidine (specialist areas only)
Amphotericin (specialist areas only)
Deoxyribonuclease (DNase):
Used in the treatment of cystic fibrosis (contact the cystic fibrosis nurse
specialists.
In some areas, drugs other than the above may be available for use via a
nebuliser. It is essential to refer to local policy in these circumstances.
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Appendix 2
PRINCIPLE RATIONALE
The nebuliser chamber should be a Budesonide and Fluticasone are
1 Pari or Ventstream circuit (Contact
viscous liquids and therefore need to
Respiratory Nurse Specialist for be nebulised via an appropriate
advice re. ordering). system which allows increased lung
deposition.
A mouthpiece must be used not a The holes in a face mask direct
2 facemask. vapour into the eyes and this could
potentially cause problems to the
eyes. A mouthpiece reduces the risk
of skin irritation.
3 Budesonide or fluticasone should Possible drug incompatibility. Volume
not be mixed with another of solution may be too large.
nebulised solution.
Encourage patient to rinse mouth To reduce the risk of oral thrush.
4 with water and spit out after Reduce systemic side effects.
nebulisation.
5 After each use, discard the To reduce the risk of colonisation of
remaining fluid. the equipment.
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All equipment should be replaced To reduce the risk of the nebuliser jet
6 when soiled. becoming blocked.
Appendix 3
Owing to the potential for droplet dispersal into the atmosphere a filtered
system is required. These guidelines should be followed alongside the
procedure for administration of a single dose nebuliser in adults.
PRINCIPLE RATIONALE
Prior to the commencement of Respiratory Nurse Specialist will be
1 treatment please contact the able to advise on the procedure and
Respiratory Nurse Specialist. identify where stocks of the required
filter system are held.
Check drug and expiry date. To ensure correct dilution and dosage
2 Reconstitute the prescribed drug as of solution.
recommended in the
manufacturers literature or
pharmacy advice.
3 Assemble the appropriate filter To avoid the risk of dispersal of drug
system (Pari or Ventstream). into the atmosphere.
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PRINCIPLE RATIONALE
5 Encourage patient to rinse mouth To reduce systemic side effects
with water and spit out after
nebulisation.
6 After each use, discard the To reduce the risk of colonisation of
remaining fluid. the equipment.
8 Discard the disposable filter from To reduce the risk of cross infection.
the Pari system after each dose.
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Equality and Diversity Statement
All patients, employees and members of the public should be treated fairly and
with respect, regardless of age, disability, gender, marital status, membership or
non-membership of a trade union, race, religion, domestic circumstances,
sexual orientation, ethnic or national origin, social & employment status, HIV
status, or gender re-assignment.
All trust polices and trust wide procedures must comply with the relevant
legislation (non exhaustive list) where applicable:
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