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every breath for you

Neb lauA Refresher for Nurses

“When you're a nurse you know that every day

you will touch a life or a life will touch you”

It is this truth that makes your role as vital as the

treating physician, in gifting a better quality of life to a

patient, particularly when it comes to those who

struggle to breathe every time.

Cipla has always been in the forefront to support

healthcare in India and towards providing the best

care for those struggling to breathe, we are all

the more committed.

In this regard, we realize your role as vital and hence

have designed an update called NEBULA - A Refresher

for Nurses on Airways Disease Management.

This booklet captures the essential information on

Airways Diseases which will help you in your day to

day interface with patients.

PREAMBLE

Normal airway:The lumen is wide without any swelling or constriction.

Asthmatic airway:Muscles around the airway are tightened up resulting in or narrowing the airway lining called as- BRONCHOSPASM, while swelling & redness in airway lining is termed as INFLAMMATION. Along with

WHAT IS ASTHMA?

Asthma is a chronic inflammatory disease characterized by airway hyper-responsiveness to a variety of stimuli resulting in bronchospasm which reverses, spontaneously or with treatment.

Many people suffer due to asthma across all age groups. Asthma often begins in childhood. Many of the asthmatics are children of age group below 5 years.

WHAT IS ABC OF ASTHMA?

A= Airway hyperresponsivenessB= BronchoconstrictionC= Chronic inflammation.

Normal airway:The lumen is wide without any swelling or constriction.

Asthmatic airway:Muscles around the airway are tightened up resulting in or narrowing the airway lining called as- BRONCHOSPASM, while swelling & redness in airway lining is termed as INFLAMMATION. Along with

WHAT IS ASTHMA?

Asthma is a chronic inflammatory disease characterized by airway hyper-responsiveness to a variety of stimuli resulting in bronchospasm which reverses, spontaneously or with treatment.

Many people suffer due to asthma across all age groups. Asthma often begins in childhood. Many of the asthmatics are children of age group below 5 years.

WHAT IS ABC OF ASTHMA?

A= Airway hyperresponsivenessB= BronchoconstrictionC= Chronic inflammation.

What are the symptoms of asthma?

Cough • Wheezing • Breathlessness or Dysponea • Chest Tightness

Asthma is on rise….This may be because of various reasons like increasing pollution, industrialization, changes in lifestyle, eating habits, junk food.

Triggers

Triggers are things that when inhaled can start asthma. They can vary from person to person.

Recognition of triggers and avoiding them is the

first step towards controlling asthma.

Mild intermitted

Mild persistent

Moderate persistent

Severe persistent

Modearate

Severe

Life threatening

Chronic asthmaAcute exacerbation

Asthma a presentation

What are the symptoms of asthma?

Cough • Wheezing • Breathlessness or Dysponea • Chest Tightness

Asthma is on rise….This may be because of various reasons like increasing pollution, industrialization, changes in lifestyle, eating habits, junk food.

Triggers

Triggers are things that when inhaled can start asthma. They can vary from person to person.

Recognition of triggers and avoiding them is the

first step towards controlling asthma.

Mild intermitted

Mild persistent

Moderate persistent

Severe persistent

Modearate

Severe

Life threatening

Chronic asthmaAcute exacerbation

Asthma a presentation

How to manage acute asthma?

Acute asthma management requires high doses of drugs which will help to open the airways, i.e. bronchodilators like Asthalin, Levolin, Ipravent or Duolin.

The rise in inflammation also needs to be taken care of; hence anti-inflammatory drugs are also given like Flohale, Budecort or Budesal.

All these drugs needs to given at high doses, which can be conveniently given via a NEBULIZER.

What is acute exacerbation of asthma?

It is also known as asthma attack or acute asthma. It is an episode of progressive increase in shortness of breath, cough, wheezing, or chest tightness, or some combination of these symptoms.

All patients with asthma irrespective of their

severity; are at a risk of developing an acute

attack…

Along with symptoms acute asthma can also be identified by some signs like:

• Inability to complete a sentence• Tachycardia [rapid heart beats]• Tachypnea [rapid breathing]• Accessory respiratory muscle use [around neck]• Excessive sweating• Cyanosis [blue discoloration of skin, lips in acute severe cases]

How to manage acute asthma?

Acute asthma management requires high doses of drugs which will help to open the airways, i.e. bronchodilators like Asthalin, Levolin, Ipravent or Duolin.

The rise in inflammation also needs to be taken care of; hence anti-inflammatory drugs are also given like Flohale, Budecort or Budesal.

What is acute exacerbation of asthma?

It is also known as asthma attack or acute asthma. It is an episode of progressive increase in shortness of breath, cough, wheezing, or chest tightness, or some combination of these symptoms.

All patients with asthma irrespective of their

severity; are at a risk of developing an acute

attack…

Along with symptoms acute asthma can also be identified by some signs like:

• Inability to complete a sentence• Tachycardia [rapid heart beats]• Tachypnea [rapid breathing]• Accessory respiratory muscle use [around neck]• Excessive sweating• Cyanosis [blue discoloration of skin, lips in acute severe cases]

Causes of COPDCOPDChronic Obstructive Pulmonary Disease.

Chronic -means long-term i.e. will not go away.Obstructive - means the airways are partly blockedPulmonary - means related to the lungsDisease - means illness

What causes COPD?

COPD is commonly linked to cigarette smoking. Smoking has already been associated with lung cancer and heart diseases but it also leads to COPD. Other risk factors are:

1. Occupational exposures to smoke2. Exposure to indoor pollution like chulla smoke3. Exposure to outdoor pollution like exhausts from

vehicles

Smoking

Chullah smoke Occupational exposure

Pollution

Causes of COPDCOPDChronic Obstructive Pulmonary Disease.

Chronic -means long-term i.e. will not go away.Obstructive - means the airways are partly blockedPulmonary - means related to the lungsDisease - means illness

What causes COPD?

COPD is commonly linked to cigarette smoking. Smoking has already been associated with lung cancer and heart diseases but it also leads to COPD. Other risk factors are:

1. Occupational exposures to smoke2. Exposure to indoor pollution like chulla smoke3. Exposure to outdoor pollution like exhausts from

vehicles

Smoking

Chullah smoke Occupational exposure

Pollution

How to manage acute COPD?

Acute COPD management requires high doses of drugs which will help to open the airways, i.e. bronchodilators like Asthalin, Levolin, Ipravent or Duolin.

What are the symptoms of COPD?

•• Exertional dyspnoea• Continuous and progressive breathlessness

What is the difference between asthma & COPD?

What is acute exacerbation of COPD?

It is an event in the natural course of the disease characterized by a change in the patient`s day to day breathlessness, cough and/or sputum; and it is often acute in onset. This may require change in regular medication.

Continuous and productive cough

Young age at onset

Sudden onset of disease

Smoking history

Allergy

Dyspnoea

Wheezing

Coughing

Sputum Production

Sometimes

Seldom

OftenOften

Sometimes

FACTORAsthma COPD

Almost neverAlmost never

Almost always

SometimesOften

Sometimes

Present in

How to manage acute COPD?

Acute COPD management requires high doses of drugs which will help to open the airways, i.e. bronchodilators like Asthalin, Levolin, Ipravent or Duolin.

What are the symptoms of COPD?

•• Exertional dyspnoea• Continuous and progressive breathlessness

What is the difference between asthma & COPD?

What is acute exacerbation of COPD?

It is an event in the natural course of the disease characterized by a change in the patient`s day to day breathlessness, cough and/or sputum; and it is often acute in onset. This may require change in regular medication.

Continuous and productive cough

Young age at onset

Sudden onset of disease

Smoking history

Allergy

Dyspnoea

Wheezing

Coughing

Sputum Production

Sometimes

Seldom

OftenOften

Sometimes

FACTORAsthma COPD

Almost neverAlmost never

Almost always

SometimesOften

Sometimes

Present in

What are the advantages of nebulizer over

injectables and orals?

Where nebulizers are used?

• Acute attacks of asthma and COPD• ICUs• Ward, post operative• At home, when the patient can’t use other

inhaler devices.• Infants, children and elderly patients who can’t

use other inhaler devices.

Nebulization

What is a NEBULIZER?

It is a device that converts liquid drug into a fine mist or aerosol which can be inhaled into the lungs within a short period, 5-10 mins. It is the form of inhaler treatment used for acute asthma & COPD.

Why nebulization?

• Immediate relief is required which can be achieved only from inhalation therapy.

• Patient is critical hence unable to co-ordinate with inhaled devices like inhaler and Rotahaler.

• Nebulization is the best resort to give optimal dose and targeted drug delivery.

Over Injectables Over Orals

Targeted drug delivery Targeted drug delivery

Lesser side effects Lesser side effects

Non invasive / Painless Faster onset of action

Easy to use Very useful in acute cases

What are the advantages of nebulizer over

injectables and orals?

Where nebulizers are used?

• Acute attacks of asthma and COPD• ICUs• Ward, post operative• At home, when the patient can’t use other

inhaler devices.• Infants, children and elderly patients who can’t

use other inhaler devices.

Nebulization

What is a NEBULIZER?

It is a device that converts liquid drug into a fine mist or aerosol which can be inhaled into the lungs within a short period, 5-10 mins. It is the form of inhaler treatment used for acute asthma & COPD.

Why nebulization?

• Immediate relief is required which can be achieved only from inhalation therapy.

• Patient is critical hence unable to co-ordinate with inhaled devices like inhaler and Rotahaler.

• Nebulization is the best resort to give optimal dose and targeted drug delivery.

Over Injectables Over Orals

Targeted drug delivery Targeted drug delivery

Lesser side effects Lesser side effects

Non invasive / Painless Faster onset of action

Easy to use Very useful in acute cases

What are the parts of nebulizer?

Compressor The compressor is the portable pump which provides power for nebulizer.• Keep the pump covered when not in use • Wipe over with a damp cloth if it gets dusty • If a filter is fitted it will need replacing or

cleaning depending on the manufacturers instructions

What are the types of nebulizers?

Jet nebulizer: •

air technology• Widely used• Economical• Any form of liquid can be

nebulized

Ultrasonic nebulizer:• Based on high frequency sound

waves technology• Finest mist and better

deposition• Not preferable for suspensions• Reduced sound• Costly, thus limits its use

Based on compressed

Compressor Tubing Nebulization chamber

Mask/Mouthpiece

What are the parts of nebulizer?

Compressor The compressor is the portable pump which provides power for nebulizer.• Keep the pump covered when not in use • Wipe over with a damp cloth if it gets dusty • If a filter is fitted it will need replacing or

cleaning depending on the manufacturers instructions

What are the types of nebulizers?

Jet nebulizer: •

air technology• Widely used• Economical• Any form of liquid can be

nebulized

Ultrasonic nebulizer:• Based on high frequency sound

waves technology• Finest mist and better

deposition• Not preferable for suspensions• Reduced sound• Costly, thus limits its use

Based on compressed

Compressor Tubing Nebulization chamber

Mask/Mouthpiece

half water and half vinegar. Rinse well then blow through with the air pump on for a few seconds. Don't wipe out!

• Nebulizer chamber needs replacing when they start to leak.

• If the chamber is taking longer than normal to nebulize the drug solution, it may be that there is a need of a new chamber.

Face mask and Mouthpiece• These should be sterilised in the same way as the

chamber, at least twice a week. • They should be replaced incase of crack, or the

face mask doesn't fit properly.

Tubing•• If some condensation in the tubing is noticed,

take off the nebulization chamber, turn on the air pump and blow out the condensation by shaking the tubing

• Replace the tubing if any dirt is seen in it, or cracks appear

Nebulization Chamber The nebulizer is the small chamber into which the liquid medicine is put and through which the air is blown to make a mist.• This needs to be rinsed in warm water after every

use. This is because the medicine comes in a salt solution and some may get left in the bowl. This can crystallize and block up the outlets.

• After rinsing the chamber, connect up tubing to it, switch on pump, blow air through for a few seconds. Do not wipe out!

• Ideally the chamber also needs to sterilised weekly if it is used regularly. Soak for half an hour in

This does not require washing

half water and half vinegar. Rinse well then blow through with the air pump on for a few seconds. Don't wipe out!

• Nebulizer chamber needs replacing when they start to leak.

• If the chamber is taking longer than normal to nebulize the drug solution, it may be that there is a need of a new chamber.

Face mask and Mouthpiece• These should be sterilised in the same way as the

chamber, at least twice a week. • They should be replaced incase of crack, or the

face mask doesn't fit properly.

Tubing•• If some condensation in the tubing is noticed,

take off the nebulization chamber, turn on the air pump and blow out the condensation by shaking the tubing

• Replace the tubing if any dirt is seen in it, or cracks appear

Nebulization Chamber The nebulizer is the small chamber into which the liquid medicine is put and through which the air is blown to make a mist.• This needs to be rinsed in warm water after every

use. This is because the medicine comes in a salt solution and some may get left in the bowl. This can crystallize and block up the outlets.

• After rinsing the chamber, connect up tubing to it, switch on pump, blow air through for a few seconds. Do not wipe out!

• Ideally the chamber also needs to sterilised weekly if it is used regularly. Soak for half an hour in

This does not require washing

How to use Nebulizers?

Breathing pattern of patient•• Occasional deep breath

Prefer the facemask when patient is …• Too critical• Unconscious• Pediatric

Prefer mouthpiece when patient is … • Comfortable enough to hold the mouthpiece• Receiving anticholinergics • Receiving steroids

Steady normal breathing

Important aspects to remember:

Fill Volumes •

chamber is usually 2-4 ml.

Nebulization Time• Time from starting nebulization until continuous

nebulization has ceased.• For bronchodilators it should be <10 mins.

Nebulization End point• Patients should be nebulized for about a minute

after 'spluttering' sound occurs. • Residual volume of 0.5 to 1 ml will always remain in

the nebulizer.

Driving gas flow rate• Most jet nebulizers work at a flow rate of 6-8 l/min.• Oxygen can be used if a compressor is not

available.

Ideal volume to be put in the nebulization

Breathing pattern of patient•• Occasional deep breath

Prefer the facemask when patient is …• Too critical• Unconscious• Pediatric

Prefer mouthpiece when patient is … • Comfortable enough to hold the mouthpiece• Receiving anticholinergics • Receiving steroids

Steady normal breathing

Important aspects to remember:

Fill Volumes •

chamber is usually 2-4 ml.

Nebulization Time• Time from starting nebulization until continuous

nebulization has ceased.• For bronchodilators it should be <10 mins.

Nebulization End point• Patients should be nebulized for about a minute

after 'spluttering' sound occurs. • Residual volume of 0.5 to 1 ml will always remain in

the nebulizer.

Driving gas flow rate• Most jet nebulizers work at a flow rate of 6-8 l/min.• Oxygen can be used if a compressor is not

available.

Ideal volume to be put in the nebulization

Cleaning:

•instructions. Neglecting to do so will promote bacteria growth in liquid remained in chamber.

• Store nebulizer and accessories in a clean, dry, and dust-free location.

• Dispose off nebulizer tubing that becomes cloudy or retains moisture very often.

• Replace disposable parts, tubing, and filters according to manufacturer’s instructions. Using a nebulizer cup longer than indicated will result in slower, less efficient delivery of medication.

• When using a nebulizer, always use a mask or mouthpiece when giving or taking a treatment. Simply aiming the mist at a baby’s face does not ensure that any medication reaches small, swollen airways.

• If treating infants and toddlers, purchase supplies that can be used when the child is in a reclined position or sleeping.

After the use of nebulizer, clean it according to

Respirator Solution••Before use it is important to d i l u t e this drug in normal saline in ratio of 1:3•Care should be taken that a f t e r dilution total volume in the chamber should not exceed 4 ml.

Respules •Respule is an ampoule containing liquid drug to be nebulized.•It contains drug which is pre diluted and hence can be used directly. •Respule should be twisted and liquid should be directly poured into the nebulization chamber.

For better response and to avoid inconvenience

respules should be preferred.

Contains the drug to be nebulized.

Cleaning:

•instructions. Neglecting to do so will promote bacteria growth in liquid remained in chamber.

• Store nebulizer and accessories in a clean, dry, and dust-free location.

• Dispose off nebulizer tubing that becomes cloudy or retains moisture very often.

• Replace disposable parts, tubing, and filters according to manufacturer’s instructions. Using a nebulizer cup longer than indicated will result in slower, less efficient delivery of medication.

• When using a nebulizer, always use a mask or mouthpiece when giving or taking a treatment. Simply aiming the mist at a baby’s face does not ensure that any medication reaches small, swollen airways.

• If treating infants and toddlers, purchase supplies that can be used when the child is in a reclined position or sleeping.

After the use of nebulizer, clean it according to

Respirator Solution••Before use it is important to d i l u t e this drug in normal saline in ratio of 1:3•Care should be taken that a f t e r dilution total volume in the chamber should not exceed 4 ml.

Respules •Respule is an ampoule containing liquid drug to be nebulized.•It contains drug which is pre diluted and hence can be used directly. •Respule should be twisted and liquid should be directly poured into the nebulization chamber.

For better response and to avoid inconvenience

respules should be preferred.

Contains the drug to be nebulized.

Things to remember:

Do’s• Nebulizer's parts should be checked regularly.• Separate masks should be used for adults and

children• Disinfection of mask should be done after each

use.• Patient should be instructed to sit upright and

breathe normally (normal steady breaths).• Combination should be preferred over mixing two

drugs.• Hygiene should be maintained.• Nebulization has to be done by a trained person.• Respules should be preferred over respirator

solution• Mouth should be rinsed after nebulizing steroids to

avoid oral thrush.• Nebulizer should be kept upright.

•replacement batteries handy.

• Only use medications made specifically for nebulizers.

Precaution to avoid infection

Since the aerosol from the nebulizer goes directly inside the lungs, there is a chance if aerosol is contamineted, consequently lungs can be infected. Following are the precautions that ought to be observed.• Wash hands thoroughly before opening the cup

of the nebulizer.• Respules should be carefully opened and

contents poured into a thoroughly clean and dry nebulization chamber.

Keep nebulizer batteries charged or have

Things to remember:

Do’s• Nebulizer's parts should be checked regularly.• Separate masks should be used for adults and

children• Disinfection of mask should be done after each

use.• Patient should be instructed to sit upright and

breathe normally (normal steady breaths).• Combination should be preferred over mixing two

drugs.• Hygiene should be maintained.• Nebulization has to be done by a trained person.• Respules should be preferred over respirator

solution• Mouth should be rinsed after nebulizing steroids to

avoid oral thrush.• Nebulizer should be kept upright.

•replacement batteries handy.

• Only use medications made specifically for nebulizers.

Precaution to avoid infection

Since the aerosol from the nebulizer goes directly inside the lungs, there is a chance if aerosol is contamineted, consequently lungs can be infected. Following are the precautions that ought to be observed.• Wash hands thoroughly before opening the cup

of the nebulizer.• Respules should be carefully opened and

contents poured into a thoroughly clean and dry nebulization chamber.

Keep nebulizer batteries charged or have

Cipla Respules: A Quality Apart

We manufacture 91 million respules per year

We make each one like there is only one

The state-of-Art manufacturing facility

Don’ts•

not be used.• Level of liquid in chamber should not exceed 4.5

ml.• Patient should be instructed not to talk during

nebulization.• Drug should not reach the eyes. Can cause other

complications.• Spluttering sound indicates drying up of the drug

i.e. end point of nebulization. • Not to talk during the nebulization.

To prevent attacks in future, asthmatic patients are recommended to take regular anti-inflammatory drugs as maintenance therapy with MDI or DPI.

Cracked & jammed chambers and tubes should

Cipla Respules: A Quality Apart

We manufacture 91 million respules per year

We make each one like there is only one

The state-of-Art manufacturing facility

Don’ts•

not be used.• Level of liquid in chamber should not exceed 4.5

ml.• Patient should be instructed not to talk during

nebulization.• Drug should not reach the eyes. Can cause other

complications.• Spluttering sound indicates drying up of the drug

i.e. end point of nebulization. • Not to talk during the nebulization.

To prevent attacks in future, asthmatic patients are recommended to take regular anti-inflammatory drugs as maintenance therapy with MDI or DPI.

Cracked & jammed chambers and tubes should

FFS Pack (Form Fill & Seal pack)

•USP# & PDA*

• Completely automated technology with very limited human intervention

• Dramatic reduction in potential of contamination• Ensures very high degree of sterility

# United States Pharmacopeia* Parenteral Drug association

Recognized as “Advanced Aseptic process” by

Anti-Static walls

• Prevent any dust & microbes & hence maintain the environment pure & sterile

FFS Pack (Form Fill & Seal pack)

•USP# & PDA*

• Completely automated technology with very limited human intervention

• Dramatic reduction in potential of contamination• Ensures very high degree of sterility

# United States Pharmacopeia* Parenteral Drug association

Recognized as “Advanced Aseptic process” by

Anti-Static walls

• Prevent any dust & microbes & hence maintain the environment pure & sterile

Volume weight checker

• High degree of assurance for accurate volume in each respule

Pinhole inspector

• Individual respule is checked for pinhole of 0.2 microns size

• Ensures leak-proof packaging

Volume weight checker

• High degree of assurance for accurate volume in each respule

Pinhole inspector

• Individual respule is checked for pinhole of 0.2 microns size

• Ensures leak-proof packaging

Light protected pouch

• Protects the product from light• Offers a tamper evident seal

Twist and squeeze mechanism

• Offers ease to patient/user to remove the liquid• Tamper-proof seal for the respule

Light protected pouch

• Protects the product from light• Offers a tamper evident seal

Twist and squeeze mechanism

• Offers ease to patient/user to remove the liquid• Tamper-proof seal for the respule

Neb lauA Refresher for NursesA Refresher for Nurses

WORLD’S WIDEST RANGE OF RESPULES AND RESPIRATOR SOLUTIONSWORLD’S WIDEST RANGE OF RESPULES AND RESPIRATOR SOLUTIONS

NOTES NOTES

every breath for you

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