Medication Administration: Metered-Dose Inhalers - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

Verify that the patient has sufficient strength to depress the canister to discharge the medication and adequate coordination during the breathing cycle.

Notify the practitioner if no improvement, a deterioration from baseline, a significant increase in heart rate, or a cardiac arrhythmia occurs after medication administration. These changes may require changes in medication dosing.

Take steps to eliminate interruptions and distractions during medication preparation.

OVERVIEW

A pressurized metered-dose inhaler (pMDI) is a device used to administer a medication through the inhalation route.^{undefined#ref1">1,2} It is a hand-held device that disperses medications through an aerosol spray or mist that penetrates the lung airways (Figure 1). The deeper passages of the respiratory tract provide a large surface area for medication absorption, and the alveolar capillary network absorbs medication rapidly.

Inhaled medications are usually designed to produce local effects; for example, bronchodilators open narrowed bronchioles. However, because these medications are absorbed rapidly through pulmonary circulation, some have the potential for producing systemic side effects (e.g., albuterol may cause palpitations, tremors, and tachycardia).

Many patients with a chronic respiratory disease receive medications by inhalation. Inhaled medications provide control of airway hyperactivity or constriction. Because patients depend on these medications, they must learn about them and learn how to self-administer them safely.

A pMDI delivers a measured dose of the medication with each push of a canister. This is a problem for some older adult patients because hand strength diminishes with age. Because using a pMDI requires coordination during the breathing cycle, many patients are able to spray only the back of their throat and fail to receive a full dose (Box 1) Box 1 . To ensure that the medication reaches the lower airways, the inhaler must be depressed to discharge the medication just as the patient inhales.

A spacer or breath-activated inhaler helps resolve administration issues caused by poor coordination. A spacer traps medication released from the pMDI, and the patient then inhales the medication from the device. These devices improve delivery of the correct dose of inhaled medication by increasing pulmonary deposition. Use of a spacer and mask is best for a small child.¹

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.
Explain the reasons for the medication. Ensure that the patient knows the proper sequence and spacing of medications if two types of medications (e.g., a bronchodilator and an inhaled corticosteroid) are to be used at the same time.
Explain the procedure to the patient. Be specific if the patient wishes to self-administer the medication.
Explain to the patient the importance of managing medication information to identify and resolve discrepancies.³
Instruct the patient regarding the potential side effects and adverse reactions of the medication.
Teach the patient the signs and symptoms of adverse reactions (e.g., increased shortness of breath) and provide instructions on when to seek additional care.
Teach the patient how to assemble and prime the device and administer a dose of medication.
Ask the patient to repeat the procedure independently to demonstrate proficiency.
Provide the patient with written instructions for use of the device and the frequency of medication administration.
Teach the patient how to keep track of the number of inhalation doses in the pMDI if a dose counter is not available (Box 2).
Teach the patient to gargle, rinse the mouth with water, and spit out the water after inhaling a corticosteroid.
Teach the patient to store the medication at room temperature and away from direct sunlight and humidity.¹
Instruct the patient to clean the plastic container of the pMDI at least once a week per the manufacturer’s instructions.²
Instruct the patient to clean the spacer before first use and then periodically based on the manufacturer’s instructions.²
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 the risk of exposure to bodily fluids.
Introduce yourself to the patient.
Verify the correct patient using two identifiers.
Assess the patient’s baseline vital signs.
Determine the patient’s respiratory status.
Assess the patient for specific contraindications to receiving the medication and advise the practitioner accordingly.
If the patient was previously instructed in self-administration of inhaled medicine, evaluate the patient’s technique when using an inhaler.

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.
Review the medication schedule and the number of inhalations prescribed for each dose.
Write the discard date on the label of the inhaler. Consult the manufacturer’s instructions or the organization’s practice for the date.
Assist the patient to a comfortable sitting or semi-Fowler position as tolerated. If not tolerated, elevate the head of the bed.
Rationale: Placing the patient in a sitting or semi-Fowler position or raising the head of the patient’s bed improves medication delivery to the lower airways.

PROCEDURE

Administration of an Inhaled Dose of Medication without a Spacer Device

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.
Insert the medication canister into the pMDI chamber.
Shake the pMDI well.
Remove the mouthpiece cover from the pMDI.
Instruct the patient to hold the inhaler in the dominant hand with the thumb at the base of the mouthpiece and the index and middle fingers at the top of the canister.
If the pMDI is new or has not been used for several days, instruct the patient to prime it by pointing it into the air (away from anyone) and actuating the device one to four times according to the package label.²
Instruct the patient to exhale completely.
Teach the patient either of these techniques:
1. Closed-mouth technique: Instruct the patient to place the mouthpiece in the mouth with the opening toward the back of the throat and to close the lips tightly around it (Figure 2). Make sure the patient’s tongue is flat under the mouthpiece and does not block the pMDI.
  When administering an anticholinergic medication, the patient should use the closed-mouth technique or a spacer device to prevent the medication from spraying into the eyes because this can increase intraocular pressure.
2. Open-mouth technique: Instruct the patient to place the pMDI two finger widths away from the lips (Figure 3) and to place the inhaler behind the fingers with the opening toward the back of the throat. Instruct the patient not to allow the lips to touch the inhaler.²
Instruct the patient to tilt the head back slightly, inhale slowly and deeply through the mouth, and exhale normally; then inhale normally to full lung capacity while pressing down on the medication canister and breathing in slowly.
Explain that the patient may feel a gagging sensation when droplets of the medication hit the pharynx or tongue.
Instruct the patient to hold the breath for up to 10 seconds² and then to relax and breathe normally.
Rationale: Holding the breath allows the medication to reach deep into the lungs.
Instruct the patient to wait 1 minute between inhalations of the same medication.²
Rationale: Waiting between puffs permits the second puff to penetrate the lungs better.

Caution the patient not to repeat inhalations before the next scheduled dose (Box 1).
Instruct the patient to rinse the mouth with warm water and then spit the water out after each pMDI use, especially when using corticosteroids.²
Assist the patient to a comfortable position.
Disinfect the pMDI and return it to the appropriate storage location.
Discard supplies, remove PPE, and perform hand hygiene.
Document the procedure in the patient’s record.

Administration of an Inhaled Dose of Medication Using a Spacer Device

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.
Insert the medication canister into the pMDI chamber.
Shake the inhaler well.
Remove the mouthpiece cover from the pMDI and the mouthpiece of the spacer device.
If the pMDI is new or has not been used for several days, instruct the patient to prime it by pointing it into the air (away from anyone) and actuating the device one to four times according to the package label.^1,2
Insert the pMDI into the end of the spacer.
Instruct the patient to exhale completely.²
Instruct the patient to place the mouthpiece of the spacer device into the mouth and to close the lips (Figure 3).
Instruct the patient to depress the medication canister, spraying one puff into the spacer.²
Rationale: The spacer device contains the fine spray and allows the patient to inhale more of the medication.
Instruct the patient to inhale deeply and slowly through the mouth (Figure 4). If a whistling sound is heard from the chamber, instruct the patient to slow the rate of inhalation.
Instruct the patient to hold a full breath for up to 10 seconds.²
Rationale: Holding the breath ensures distribution of the medication particles into the deeper airways.
Instruct the patient to breathe in through the spacer again to ensure that all of the medication is received.
Instruct the patient to wait 1 minute between puffs of the same medication.²
Caution the patient not to repeat inhalations before the next scheduled dose (Box 1).
Instruct the patient to rinse the mouth with warm water and then spit the water out after each pMDI use, especially when using corticosteroids.²
Assist the patient to a comfortable position.
Disinfect the pMDI and return it to the appropriate storage location.
Discard supplies, remove PPE, and perform hand hygiene.
Document the procedure in the patient’s record.

MONITORING AND CARE

Assess the patient’s vital signs and respiratory status.
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.

EXPECTED OUTCOMES

Medication is administered per the six rights of medication safety.
Patient correctly describes and demonstrates techniques for using pMDI.
Patient correctly self-administers the medication.
Patient’s breathing pattern improves, and airways become less restricted.
Patient’s gas exchange is adequate.
Patient experiences no adverse effects.

UNEXPECTED OUTCOMES

Medication is not administered per the six rights of medication safety.
Patient experiences paroxysms of coughing from aerosolized particles that irritate posterior pharynx.
Patient experiences light-headedness or syncope, especially if receiving beta-adrenergics.
Patient is not able to self-administer medication properly.
Patient’s respirations are rapid and shallow; breath sounds indicate wheezing.

DOCUMENTATION

Education
Medication name, dose, and route
Time and date of medication administration
Patient’s response to medication, including any adverse reactions
Patient’s ability to perform skills as instructed
Comprehensive list of current medications and those recently discontinued
Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS

Because of difficulty coordinating inhaler activation and inhalation, a spacer device is recommended for young children.

OLDER ADULT CONSIDERATIONS

For some older adult patients, a spacer device is recommended because the patient has difficulty coordinating inhaler activation and inhalation or has a weakened grip.

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. (2017). A guide to aerosol delivery devices for respiratory therapists (4th ed.). American Association for Respiratory Care. Retrieved August 15, 2023, from https://www.aarc.org/wp-content/uploads/2018/01/aerosol-guides-for-rts-4th.pdf (classic reference)* (Level VII)
Joint Commission, The. (2023). National Patient Safety Goals for the hospital program. Retrieved August 15, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf (Level VII)

ADDITIONAL READINGS

Schmitz, D.C. and others. (2019). Imperative instruction for pressurized metered-dose inhalers: Provider perspectives. Respiratory Care, 64(3), 292-298. doi:10.4187/respcare.06302

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Adapted from Perry, A.G. and others (Eds.). (2022). Clinical nursing skills and techniques (10th ed.). St. Louis: Elsevier.

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: Suzanne M. Casey, MSN-Ed, RN

Published: October 2023