Medication Administration: Nebulized (Pediatric) - CE/NCPD

ALERT

If bronchospasm occurs during nebulized medication administration, discontinue the medication and notify the practitioner.

Take steps to eliminate interruptions and distractions during medication preparation.

OVERVIEW

Nebulization is the process of aerosolizing a medication. Nebulized treatments can be given either intermittently or continuously. Medications such as bronchodilators, mucolytics, corticosteroids, antimicrobials, and antivirals are often administered by nebulization.

The primary advantage of nebulized medication administration is that it treats the lung directly, avoiding systemic effects.^{undefined#ref1">1} In addition, minimal patient cooperation is required for the treatment. The disadvantage is that lung deposition of the nebulized medication represents a relatively low fraction of the total dose. Development of appropriate approaches that minimize distress is essential for administering nebulized medications to a pediatric patient.

Selection of the correct nebulizer device is critical for successful administration in infants and children. Small-volume nebulizers provide medications in an aerosolized form that the infant or child can inhale into the tracheobronchial tree (Figure 1). Young children may not use a mouthpiece reliably. If the patient cannot hold a mouthpiece between the lips, a face mask should be used (Figure 1). If a face mask is used, the appropriate size should be selected to avoid loss of medication. If the patient is in distress, forcing the mask will agitate the patient and may worsen respiratory distress. Involving the family to help calm the patient and promote cooperation is essential.

Nebulizer sets must be cleaned appropriately; failure to do so leads to a decrease in performance due to clogging of the output orifice on the machine. Patient and family education should include effective nebulizer cleaning techniques.

If the patient, family, or caregivers expresses concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Assess the patient’s, family’s, and caregivers’ learning readiness.
• Explain to the patient, family and caregivers the importance of managing medication information to identify and resolve discrepancies.⁴
• Provide the patient, family and caregivers with written information on the medication the patient should be taking,⁴ including its purpose and the reason for the inhaled nebulized route.
• Instruct the patient and family regarding the potential side effects and adverse reactions of the medication.
• Explain to the patient and family the step-by-step procedure for nebulized medication administration.
• Explain how the family can participate during the procedure.
• Explain how the patient can assist with the procedure by taking deep breaths.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient and family.
3. Verify the correct patient using two identifiers.
4. Review the patient’s history for reactions or allergies to medications, foods, or environmental allergens.
5. Assess the patient for specific contraindications to receiving the medication and advise the practitioner accordingly.
6. Assess the patient’s developmental level and ability to interact.
7. Assess the patient’s and family’s understanding of the reasons for and the risks and benefits of the procedure.
8. Assess baseline vital signs, breath sounds, respiratory effort, pulse oximetry reading, and, when indicated and if ordered, peak flow meter reading.
9. Determine the appropriate delivery device based on an assessment of the patient’s age, developmental level, and ability to follow instructions. If the patient cannot hold a mouthpiece between the lips, use a face mask.

Preparation

1. Verify the patient’s daily weight in kilograms. Stated, estimated, or historical weight should not be used.³
2. Obtain, update, and compare information about the medication the patient is currently taking with that of the medications ordered for the patient to identify and resolve discrepancies.⁴
3. Consider consulting a child life specialist if available.
4. Obtain the medication, check the practitioner’s order, verify the expiration date, and inspect the medication for particulates, discoloration, or other loss of integrity.

   Do not use any medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe.

5. Review medication reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, and common side effects and implications.

PROCEDURE

1. Perform hand hygiene and don gloves before patient contact. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and family and ensure that they agree to treatment.
4. Check accuracy and completeness of the medication administration record (MAR) with the practitioner’s original order.
5. Ensure the rights of medication safety. Use a bar code system or compare the MAR to the patient’s identification band.
6. Label all medications, medication containers, and other solutions. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them.⁴
7. Assemble the nebulizer equipment according to the manufacturer’s recommendations.
8. Assist the patient into a comfortable sitting or semi-Fowler position as tolerated to support full inhalation. The patient may be held in a family member’s lap for optimal positioning, as indicated.

   Rationale: A sitting or semi-Fowler position promotes optimal lung expansion and maximal distribution of aerosolized particles to lung fields.

9. Add the prescribed medication and diluent if needed to the medication cup of the nebulizer.

   Rationale: Some medications are unit dosed and prediluted; others may require a diluent such as saline to ensure optimal drug delivery.

   Check the required fill volume for the device used.

10. Turn on the small-volume nebulizer via the flowmeter. Usually, the flow rate is between 6 and 10 L/min and is listed on the device label.²

    Rationale: The correct flow rate ensures that a sufficient mist forms to indicate nebulization is occurring.

11. If a mouthpiece is used, instruct the patient to hold it with the lips, using gentle pressure to form a seal around the tip. If patient is unable to hold the mouthpiece, use a face mask.

    Rationale: A correct fit with a tight seal around the mouthpiece decreases the loss of medication into the air, ensuring delivery of the prescribed dose.

    Make sure the face mask fits tightly and instruct the patient to breathe through an open mouth.

12. Instruct the patient to take a deep breath slowly, reaching an air volume slightly greater than normal. Encourage a brief, end-inspiratory pause (breath holding). Then instruct the patient to exhale passively.

    Rationale: This technique increases optimal delivery of the medication to the lungs. Normal breathing pattern can be used with the patient’s mouth open to provide a direct route to the airways for the medication.

    Medication deposition to the lungs will vary in young children depending on their respiratory rate and depth of breathing during treatment.

13. Monitor the patient’s heart rate periodically during treatment. Discontinue treatment if the heart rate rises significantly and notify the practitioner.

    Rationale: Tachycardia is a side effect of bronchodilators; it can lead to hemodynamic instability in small infants and children.

    Be aware that side effects usually subside shortly after treatment.

14. When most of the medication dose has been delivered (indicated by sputtering in the medication cup), tap the sides of the cup to drop the medication to the bottom of the cup.

    Rationale: Tapping the sides of the cup releases droplets of medication that may adhere to sides of the medication cup. Some medications have a longer nebulization time due to increased viscosity of the liquid.

15. When treatment is complete, turn off the flowmeter and assess the patient’s response to treatment by checking the heart rate, respiratory rate, breath sounds, oxygen saturation values, and, if ordered, peak flow readings.
    1. Compare assessment findings with baseline assessment findings to evaluate treatment effectiveness.
    2. For a younger child, it may be necessary to wait several minutes after treatment to obtain an accurate heart rate and respiratory rate because the treatment may have agitated the patient.
16. Disassemble all parts of the nebulizer, shake the nebulizer cup to attempt to remove all the remaining solution, rinse each part in sterile water, shake off excess water, and allow to air-dry completely. Store the nebulizer cup and tubing assembly in a clean bag until its next use.
17. Praise the patient for positive behavior.
18. Help the patient back to a comfortable position.
19. Discard supplies, remove PPE, and perform hand hygiene.

    At the completion of the procedure, ensure all choking hazards are removed from the patient’s linens and placed in the appropriate receptacle.

20. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor the patient’s tolerance of the procedure.
2. Assess for the intended response to medication.
3. Monitor the patient for adverse and allergic reactions to the medication. Recognize and immediately treat respiratory distress and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response.

   Rationale: Nebulized medications or 0.9% sodium chloride solution may worsen bronchospasm.

   Reportable conditions: Rash, hives, respiratory distress, seizures

EXPECTED OUTCOMES

• Medications administered per the rights of medication safety
• Patient tolerates medication and experiences no adverse reactions
• The patient and family can state the purpose and side effects of the medication.
• The patient’s breathing pattern and gas exchange improve.

UNEXPECTED OUTCOMES

• Medications not administered per the rights of medication safety
• No sign of intended response to medication
• Adverse reaction to the medication
• Patient or family cannot state the purpose and side effects of the medication
• If taught to administer the medication, the patient and family are unable to do so

DOCUMENTATION

• Comprehensive list of current medications and those recently discontinued.
• Patient’s weight in kilograms
• Medication administered, dose, time of administration, person administering it
• Patient’s response to medication, including any adverse reactions
• Vital signs, oxygen saturation, pulse oximetry reading, peak flow measurements, and lung assessment
• Unexpected outcomes and related interventions
• Education

REFERENCES

1. Anderson, C.E., Herring, R.A. (2022). Chapter 20: Pediatric nursing interventions and skills. In M.J. Hockenberry, C.C. Rodgers, D. Wilson (Eds.), Wong’s essentials of pediatric nursing (11th ed., pp. 551-618). St. Louis: Elsevier.
2. Fink, J.B., Ari, A. (2021). Chapter 40: Aerosol drug therapy. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (12th ed., pp. 842-883). St. Louis: Elsevier.
3. Institute for Safe Medication Practices (ISMP). (2022). 2022-2023 Targeted medication safety best practices for hospitals. Retrieved April 11, 2023, from https://www.ismp.org/guidelines/best-practices-hospitals (Level VII)
4. Joint Commission, The. (2023). National Patient Safety Goals for the hospital program. Retrieved April 11, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf (Level VII)

ADDITIONAL READINGS

Smallwood, C, (2021). Administration of inhaled medications. OPENPediatrics^™. https://www.youtube.com/watch?v=5FgWrsT9VlY

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports