Medication Administration: Dry Powder Inhaler (Respiratory Therapy)

ALERT

Because high inspiratory flows (greater than 60 L/min) are required when using dry powder inhalers (DPIs), some patients are not good candidates for DPI use.^{undefined#ref1">1} These include infants and young children, as well as patients who either are unable to follow instructions, are experiencing bronchospasms, or have chronic obstructive pulmonary disease exacerbations.¹

Take steps to eliminate interruptions and distractions during medication preparation.

OVERVIEW

DPIs, which deliver medications to the lungs in a dry powder form, are alternatives to aerosol-based delivery systems for inhaled respiratory medications. DPIs are more portable and may be easier to use than metered-dose inhalers (MDIs) because they do not require a spacer. Therefore, DPIs may improve patient compliance.

Patients with respiratory disorders, such as asthma, bronchitis, and emphysema, may benefit from medication delivery with a DPI. Most older children can produce the inspiratory flow rate needed to use a DPI.

Because most DPIs use the force of inhalation to deliver the dry powder medication, insufficient flow rates or an ineffective inspiratory hold time can reduce the dosage delivered. DPIs are breath activated (they do not use a propellant to deliver the medication), which makes coordinating inspiration and actuation of the delivery device less necessary.

The correct use of DPIs depends on the type of delivery system used. Three types of devices are available: single-dose, multiple-dose, and multiple unit–dose inhalers (Figure 1).

The disadvantages of DPIs are that fewer drugs are available in this form and the patient must generate a sufficient inspiratory flow rate to acquire the correct dose. DPIs must be kept dry because moisture and humidity can cause the powder to clump. The dose may be lost if the patient inadvertently exhales into the DPI.

If the patient 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.
Teach the patient and family how to deliver the medication using a DPI containing a placebo, if available.
Ask the patient to repeat the procedure independently to demonstrate proficiency.
Teach the patient and family how to assemble and care for the DPI.¹
Instruct the patient regarding the potential side effects and adverse reactions to the medication.
Instruct the patient to report any adverse reactions, such as increased shortness of breath, to the authorized practitioner.
Teach the patient to store the medication at room temperature and away from direct sunlight and humidity.¹
Provide the patient with written instructions for use of the device and the frequency of medication administration.
Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
Introduce yourself to the patient.
Verify the correct patient using two identifiers.
Ensure that the patient can achieve a rapid, steady inhalation for sufficient flow.
Measure the patient’s baseline vital signs and obtain peak flow measures, if ordered.
Review the patient's medication history and identify any drug allergies.
Determine the patient's respiratory pattern and auscultate breath sounds.
Assess the patient for specific contraindications to receiving the medication and advise the practitioner accordingly.
If using a single-dose DPI, assess the patient's ability to manipulate the capsule, including removing the cap, puncturing the foil packet, and placing the capsule in the DPI.²

Preparation

Obtain the medication, check the practitioner’s order, verify the expiration date, and inspect the container for loss of integrity.
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.
Read the written instructions for the DPI, if available.
Obtain a placebo device, if available.

PROCEDURE

Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
Verify the correct patient using two identifiers.
Explain the procedure and ensure that the patient agrees to treatment.
Ensure the rights of medication safety.
Assemble the DPI according to the manufacturer’s instructions.
Load and prepare the medication for delivery according to the manufacturer’s instructions.
Instruct the patient to exhale completely (to functional residual capacity [FRC]) away from the device.
Instruct the patient to place teeth over the mouthpiece and to seal lips around it.
Instruct the patient to inhale a rapid and steady breath.²
Instruct the patient to hold a breath for 10 seconds, if able.²
Instruct the patient to breathe out slowly.
Have the patient repeat steps until the full dose is administered.
Allow the patient to rinse the mouth.
Wipe the DPI clean.
Discard supplies, remove PPE, and perform hand hygiene.
Document the procedure in the patient's record.

MONITORING AND CARE

Reassess the patient’s vital signs, including heart rate and respiratory rate.
Reassess the patient’s breath sounds and obtain peak flow measures again, if ordered.
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.
Report adverse reactions, the patient’s response, and withheld medications. Depending on the medication and the response, immediate notification of the prescribing practitioner may be required.
Observe the patient for signs and symptoms of pain. If pain is suspected, report it to the authorized practitioner.
Return the DPI medication to the medication room and store it at room temperature.

EXPECTED OUTCOMES

Patient correctly describes and demonstrates techniques for using DPI
Medication administered per the rights of medication safety
Improved vital signs
Improved subjective responses from the patient
Improved work of breathing
Prevention of bronchospasm associated with asthma and COPD
Reduced inflammatory response and mucus production

UNEXPECTED OUTCOMES

Patient not able to self-administer medication properly
Medication not administered per the rights of medication safety
Airway irritation
Bronchospasm
Increased shortness of breath

DOCUMENTATION

Education
Success of training
Medication name, dose, and route
Mouth rinsed, if applicable
Patient's vital signs before and after medication administration
Peak flow measures, if ordered
Patient's effort
Patient's response to the medication, including adverse reactions
Unexpected outcomes and related interventions

OLDER ADULT CONSIDERATIONS

Older adult patients may be unable to provide sufficient inspiratory effort to obtain the proper dose of the medication from the DPI. In this case, a different delivery device should be used.

HOME CARE CONSIDERATIONS

Medications used in DPIs should be stored properly without excessive heat or moisture.

REFERENCES

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.
Gardenhire, D.S. and others. (2023). A guide to aerosol delivery devices for respiratory therapists (5th ed.). Irving, TX: American Association for Respiratory Care. Retrieved October 9, 2023, from https://www.aarc.org/wp-content/uploads/2018/03/aersol-guides-for-rts.pdf (Level VII)

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

Clinical Review: Genevieve L. Hackney, MSN, RN
Revised: Genevieve L. Hackney, MSN, RN

Published: August 2023
Revised: November 2023