HINT: How to use a nasal atomizer to safely deliver intranasal medication

Connected Care Quick Hits are up to date and evidence based recommendations for the care of children with medical complexity & technology dependence, from hospital to home.

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HINT: How to use a nasal atomizer to safely deliver intranasal medication

SITUATION: 

This QuickHit was informed by a Connected Care Live consult from a home and community care provider inquiring how to use a nasal atomizer to deliver intranasal medication.

BACKGROUND:

Children with medical complexity often require multiple medications with select therapeutic agents prescribed as a mist to be delivered intranasally (e.g., midazolam). When a medication is sprayed into the nose, it is quickly absorbed through the inner surface of the nose, directly into the blood. 

Intranasal medications are administered with a Mucosal Atomization Device (MAD). The MAD consists of a foam applicator containing a plastic aerosolizer which attaches to the syringe with the medication drawn up from a vial. When the syringe plunger is compressed, the medication in the syringe is pushed through the aerosolizer and converted into a mist. 

ASSESSMENT:

Children will have a clear order for any intranasal medication including specific instructions on when and how to administer it, and if it is safe to repeat a dose. Review orders carefully prior to administration. 

Consider conditions which would impair intranasal medication absorption, such as trauma to the nose, blocked nasal passages, or nosebleeds.

Large amounts of mucous or blood in the nose may prevent medication absorption. If appropriate, nasal suctioning prior to administration may aid absorption.

Required Personal Protective Equipment are routine practices (i.e. a medical/surgical mask and eye protection). Before using a MAD, perform a point of care risk assessment to determine the concurrent risk of Aerosol Generating Medical Procedures (AGMPs) (e.g. child also has a tracheostomy tube). Click here for a full list of AGMPs.

Intranasal medications require preparation of the dose prior to administration. You will need:

• a MAD

• an appropriate size Luer-Lock syringe (e.g. 1 cc, 3 cc)

• a needle

• a vial of the ordered medication

• alcohol wipes

• a sharps container

RECOMMENDATION:

Steps to using a Mucosal Atomization Device (MAD)

Preparing the right dose

• Draw up the required dose into a single Luer-Lock syringe. Draw up an extra 0.1 ml of medication to account for the medication that will remain in the neck of the MAD (known as the "dead space") after administering the dose.

• Inspect the MAD before each use to ensure it is intact.

• Attach the MAD to the syringe and twist to secure.

Positioning the child for safety

• Position the child on their back or the child can sit.

• Hold the top of the head stable and place the MAD in the nostril. Rest the tip of the MAD snugly against the insides of the nostril and aim it up and outwards (e.g., toward the top of the ear).

Delivering the medication

• Consider the maximum medication volume that can be given per nostril for optimal absorption (see table below).

  • If the medication volume can be given in one nostril, then compress the syringe plunger rapidly and forcefully to expel the medication as a mist into the nostril for maximal effectiveness.

  • If dividing the medication volume between both nostrils, compress the syringe plunger rapidly and forcefully to deliver only half the syringe contents into the first nostril. Move the MAD to the other nostril and deliver the remaining syringe contents.

• Hold the MAD in the nostril for 5 to 10 seconds to ensure absorption.

• If supine, move the child to the recovery position on either side.

• Briefly compress the nostril after delivery to limit dripping/loss of medication.

Repeating a dose

• If repeating a dose, the 0.1 ml of medication remaining in the MAD will need to be expelled (pushed out) as follows:

  • Remove the MAD, fill the syringe with 1 ml of air, and re-apply the MAD.

  • Push down on the plunger forcefully and repeat until all medication is removed.

  • Draw up and administer the next dose.

Assessing the effect of the medication

• Monitor the child closely for side effects and medication effectiveness.

• Clean and store the MAD for future use.

Cleaning and storing the MAD
The MAD may be washed and reused for the same child. Remove the MAD from the syringe. Wash the MAD with mild soap and water. Rinse well. Use the syringe to rinse the MAD and then let it air dry. Once dry, place it into a safe storage container. Replace after 3-4 uses.

Consider a Connected Care Live consult to see a demonstration of the Mucosal Atomization Device (MAD).

Click here to visit AboutKidsHealth for more information about delivering intranasal medication