August 30, 2024

Welcome back to UH EMS Institute’s Pharmacy Phriday. In the next few installments, we will review the various medication routes used to administer medications in our protocol and provided through the UH EMS drug box system.  

In the last installment, we reviewed protocol changes for aerosols and the EMT basic because of the State of Ohio EMS Scope of Practice changes. Though we briefly highlighted some tips on aerosol administrations, we will take a deeper look at this medication route. 

Indications for the use of the aerosol or inhaler route are often associated with respiratory complaints such as patients experiencing bronchospasm and exhibiting signs and symptoms that may include: 

• accessory muscle use  

• fatigue  

• history of COPD or asthma  

• nasal flaring  

• shortness of breath 

• unable to speak in full sentences  

• wheezing 

Medications within the UH protocols that can be administered via the nebulized route include:  

• Albuterol 

• Ipratropium 

• the combination of Albuterol and Ipratropium 

• Racemic Epinephrine 

• Normal Saline 

• Calcium Gluconate solution for nebulizer 

Can you recall which algorithms call for some of these medications? Two of these medications can be given for toxic exposures or poisoning. Do you know which two? Do you know for what conditions? Answers to come! 

The lungs have a large surface area and are very vascular, so when inhaled medications are delivered via this route they are rapidly absorbed and reach their site of action with minimal delays. Absorption of the medication can be affected by the drug particle size, respiratory physiology of the patient, oxygen source and flow, and many other variables and can be limited in adverse circumstances.  

Medications can be administered via the inhalation route by a Metered Dose Inhaler (MDI), a Dry Powder Inhaler (DPI), or a small volume (updraft) nebulizer. In the pre-hospital, emergent setting, EMS providers most often use the nebulizer, either with a handheld mouthpiece, nebulizer mask, or CPAP unit. A nebulizer mask or CPAP nebulizer setup is used when a patient can't hold the mouthpiece, is in severe distress, is not providing adequate tidal volumes on their own, and is not improving with oxygen and standard treatments. MDIs are most often used by the patient in emergent settings. DPIs are devices used by patients for maintenance dosing only. 

Before administering any medication via any route, review the “five rights” of medication administration:  

1. right patient 

2. right drug 

3. right dose 

4. right site 

5. right timing.  

A sixth “right” is sometimes referenced: the right documentation.  

When preparing the nebulizer, pour the medication or solution into the reservoir well. These 2-3 ml solutions are usually provided as a unit dose pre-mixed solution. Sometimes the provider may be required to prepare the solution. 

Connect the nebulizer to an oxygen source and set the flow rate between 6-8 lpm. The principle of the device is that as oxygen is blown past the chamber, it causes the medication to be aerosolized. The goal of the procedure is to produce a steady visible mist. 

The preferred position for the patient is sitting upright to aid in adequate tidal volumes. Instruct the patient to form a seal around the mouthpiece of the nebulizer and to inhale deeply, attempting to hold their breath for a few seconds. If using the nebulizer mask or CPAP, connect to the device and secure a separate oxygen source. Be sure the reservoir well remains upright. In some cases, such as with a pediatric patient who will not tolerate the mouthpiece or mask, the aerosol can be given using the blow-by technique. 

Treatments last until the solution is depleted and misting ends, usually in about 5-10 minutes. Tapping the reservoir can ensure that all the medication is used. Monitor and reassess the patient, then document the treatment and results appropriately. 

Although MDIs are primarily used by patients for self-administration, the EMS provider should be aware of how these devices are used if they need to assist patients with their administration. 

Inhalers should be at room temperature when used. Follow instructions for shaking the device before use. The patient should exhale and hold the inhaler one to two inches from their mouth. They should then place their mouth on the mouthpiece, form a seal around it, and inhale slowly and deeply as they push down on the inhaler to release the medication. The patient will then hold their breath for 5 to 10 seconds and exhale through pursed lips. 

Remember that some patients are provided with devices that come with a spacer. A spacer is placed between the inhaler and mouthpiece if provided. It is often helpful for patients having difficulty timing the breathing and depressing of the inhaler, most often in a pediatric or elderly patient. If using the spacer, the patient would form a seal on the mouthpiece, push down the device to deliver the medication, then take a deep breath, holding the breath 5 to 10 seconds if possible.  

So...were you able to recall the two toxin algorithms where aerosols are called for and which medications to use? Refer to the Hyperkalemia algorithm and the use of Albuterol in those cases as well as the Toxic Exposure- Hydrogen Fluoride Exposure and the use of aerosolized Calcium Gluconate.  

Till the next installment, stay safe! 

Sincerely,



The UH EMS-I Team

University Hospitals