Medication Administration: Dry Powder Inhaler (Respiratory Therapy)

ALERT

Because high inspiratory flows are required when using dry powder inhalers (DPIs), older patients, patients with chronic obstructive pulmonary disease (COPD) exacerbations, young children, and patients who are experiencing bronchospasms are not good candidates for DPI use.^{undefined#ref2">2}

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). 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 are able to 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. Two types of devices are available: the single-dose and the multidose (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, do not give the medication. Explore the patient’s concern, notify the practitioner, and verify the order.

PATIENT AND FAMILY EDUCATION

• 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 of 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

1. Perform hand hygiene before patient contact.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Ensure that the patient is able to achieve a rapid inhalation for sufficient flow.
5. Measure the patient's baseline vital signs and peak expiratory flow rate (PEFR).
6. Review the patient's medication history and identify any drug allergies.
7. Determine the patient's respiratory pattern and auscultate breath sounds.
8. Assess the patient for specific contraindications to receiving the medication and advise the practitioner accordingly.
9. 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

1. Obtain the medication and verify the expiration date.
2. Inspect the medication for loss of integrity.
3. Understand drug reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, common side effects, and respiratory therapy implications, if needed.
4. Read the written instructions for the DPI, if available.
5. Obtain a placebo device, if available.

PROCEDURE

1. Perform hand hygiene and don gloves.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and ensure that he or she agrees to treatment.
4. Check the accuracy and completeness of the medication administration record (MAR) with the practitioner's original order.
5. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right patient, and right documentation. Use a bar code system or compare the MAR to the patient's armband.
6. Assemble the DPI according to the manufacturer’s instructions.
7. Load and prepare the medication for delivery according to the manufacturer’s instructions.
8. Instruct the patient to exhale completely (to functional residual capacity [FRC]) away from the device.
9. Instruct the patient to place his or her teeth over the mouthpiece and to seal his or her lips around it.
10. Instruct the patient to inhale rapidly and deeply.²
11. Instruct the patient to hold his or her breath for 10 seconds, if able.²
12. Instruct the patient to breathe out slowly.
13. Repeat until the full dose is administered.
14. Allow the patient to rinse his or her mouth.
15. Wipe the DPI clean or replace it if it appears dirty.
16. Discard supplies, remove gloves, and perform hand hygiene.
17. Document the procedure in the patient's record.

MONITORING AND CARE

1. Reassess the patient’s vital signs, including heart rate, respiratory rate, and breath sounds.
2. Monitor the patient for adverse and allergic reactions to the medication. Recognize and immediately treat dyspnea, wheezing, and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response.
3. 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.
4. Return the DPI medication to the medication room and store it at room temperature.
5. Observe the patient for signs and symptoms of pain. If pain is suspected, report it to the authorized practitioner.

EXPECTED OUTCOMES

• 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

• Airway irritation
• Bronchospasm
• Increased shortness of breath

DOCUMENTATION

• Patient and family education
• Success of training
• Medication given
• Mouth rinsed, if applicable
• Patient's vital signs before and after medication administration
• Patient's effort
• Patient's response to medication, including adverse reactions
• Unexpected outcomes and related interventions

GERONTOLOGICAL CONSIDERATIONS

• Older 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

1. Fink, J.B., Ari, A. (2017). Chapter 39: Aerosol drug therapy. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (11th ed., pp. 843-883). St. Louis: Elsevier.
2. Gardenhire, D.S. and others. (2017). A guide to aerosol delivery devices for respiratory therapists (4th ed.). Retrieved February 14, 2019, from http://www.aarc.org/wp-content/uploads/2018/01/aerosol-guides-for-rts-4th.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