EMS Medication Administration - Inhalation Route

EMS Providers need to have a thorough understanding of inhaled medication administration to ensure patient safety and effective treatment. 

Here are some key points they should know:

1. Indications and Contraindications

Indications:

• Respiratory distress due to conditions like asthma, chronic obstructive pulmonary disease (COPD), or anaphylaxis.
• Administration of medications such as bronchodilators (e.g., albuterol), corticosteroids, and emergency medications (e.g., epinephrine via nebulizer for severe allergic reactions).

Contraindications:

• Allergy to the medication.
• Inability of the patient to effectively inhale the medication (e.g., severe respiratory distress, altered mental status).
• Situations where the administration method (e.g., nebulizer, metered-dose inhaler) is not suitable due to specific patient conditions or environmental factors.

2. Types of Inhaled Medications

Metered-Dose Inhalers (MDIs): 

Pressurized canisters that deliver a specific dose of medication in aerosol form.

Dry Powder Inhalers (DPIs): 

• Devices that deliver medication in powder form which the patient inhales.

Nebulizers: 

• Devices that convert liquid medication into a fine mist for inhalation over several minutes.

Breath-Actuated Inhalers: 

• Devices that release medication automatically when the patient inhales.

3. Preparation and Technique

Medication Preparation:

• Verify the “Six Rights” of medication administration: right patient, right medication, right dose, right route, right time and right documentation.
• Ensure the inhaler or nebulizer is properly assembled and medication is correctly loaded.

Patient Preparation:

• Ensure the patient is in an upright position to maximize lung expansion and facilitate proper inhalation.
• Instruct the patient on how to use the inhaler or nebulizer correctly.

4. Administration Techniques

MDIs:

• Shake the inhaler well before use.
• Attach a spacer if recommended, which helps in delivering more medication to the lungs.
• Have the patient exhale fully, place the mouthpiece in their mouth, and inhale slowly and deeply while pressing the canister to release the medication.
• Instruct the patient to hold their breath for about 10 seconds before exhaling slowly.
• Wait about a minute between puffs if a second dose is needed.

DPIs:

• Load the dose according to the inhaler’s instructions.
• Have the patient exhale fully away from the inhaler, place the mouthpiece in their mouth, and inhale quickly and deeply.
• Instruct the patient to hold their breath for about 10 seconds before exhaling slowly.

Nebulizers:

• Assemble the nebulizer and add the prescribed medication to the medication cup.
• Attach the mouthpiece or mask to the nebulizer.
• Turn on the nebulizer and have the patient inhale the mist steadily until the medication is finished (usually 5-10 minutes).

5. Patient Communication and Education

Explain the Medication: 

• Inform the patient about the purpose of the medication, how it will help, and any potential side effects.

Instructions: 

• Provide clear instructions on how to use the inhaler or nebulizer, including breathing techniques and the importance of taking slow, deep breaths.

6. Monitoring and Follow-Up

Observe for Effects: 

• Monitor the patient for the expected therapeutic effects and any adverse reactions.

Reassessment: 

• Regularly reassess the patient’s respiratory status, including breath sounds, respiratory rate, and oxygen saturation, to determine the effectiveness of the medication and any need for additional intervention.

7. Complications and Management

Incorrect Usage: 

• Ensure the patient understands and correctly follows the administration technique to avoid ineffective dosing.

Adverse Reactions: 

• Be prepared to manage potential adverse reactions, such as tachycardia, tremors, or paradoxical bronchospasm.

Device Malfunction: 

• Recognize and troubleshoot any issues with the inhaler or nebulizer.

8. Special Considerations

Pediatric and Geriatric Patients: 

• Adjust instructions and consider additional challenges in administering inhaled medications to these populations, such as the use of spacers for children or coordination issues in the elderly.

Environmental Factors: 

• Ensure the environment is suitable for nebulizer use, especially in situations where power sources may be limited or there is a risk of spreading infectious aerosols.

Patient Condition: 

• Be aware of any conditions that might affect inhaled medication administration, such as severe respiratory distress, altered mental status, or inability to follow instructions.

9. Training and Proficiency

Simulation Training: 

• Regular practice using simulation models to maintain proficiency in inhaled medication administration techniques.

Continuing Education: 

• Stay updated on best practices, new medications, and techniques for inhaled administration.

10. Legal and Ethical Considerations

Scope of Practice: 

• Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent: 

• Obtain informed consent from the patient or guardian whenever possible.

Documentation: 

• Accurate documentation of medication name, dose, route, time of administration, and any observed effects or adverse reactions.

Conclusion

Effective inhaled medication administration requires EMS providers to combine theoretical knowledge with practical skills. 

Continuous training, adherence to protocols, and understanding the indications, techniques, and potential complications are essential for safe and effective patient care.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell