4.2.1 Inhaled Pentamidine
Only individuals who have been trained on the safe handling and administration of pentamidine may perform this procedure.
Purpose
The Registered Nurse or respiratory therapist administers aerosolized pentamidine to the patient for the prevention of Pneumocystis jiroveci, formerly carinii, pneumonia (PCP or PJP). PJP can be severe or fatal if not promptly treated. It can affect the lungs as well as other parts of the body, including the skin and internal organs.
Overview
Pentamidine is an antiprotozoal agent commonly used as a second-line therapy to help prevent the growth of pneumocystis jiroveci a microorganism often found in the lungs of patients who are immunosuppressed. When pentamidine is delivered as an aerosol it has limited absorption from the respiratory tract into the systemic circulation and therefore has fewer systemic side effects than when given intravenously.
Pentamidine is administered via the Respirgard II Nebulizer, which utilizes a series of one-way valves and a filter to minimize the release of aerosol droplets into the air. Aerosolized pentamidine may be potentially toxic necessitating this special nebulization system. The standard dose is 300 mg of lyophilized pentamidine isethionate dissolved in sterile water and aerosolized until the nebulizer runs dry. Inhaled pentamidine is given on a monthly basis.
Precautions
Adequate ventilation is required. Some tertiary centres conduct the procedure in a HEPA-filtered exhaust containment booth. This booth is serviced and certified every 12 months. Other centres should use a negative pressure room. If you did not have a negative pressure room use a portable HEPA filter.
Pediatric patients require a pre treatment nursing assessment. Ensure age and cooperation level of patient are congruent with the ability to receive inhaled pentamidine. Do not administer pentamidine to pregnant patients, unless clearly indicated. Staff may experience irritation of the conjunctivae or respiratory system, or respiratory or skin allergies if overexposed to pentamidine. Staff must administer pentamidine using all appropriate precautions to minimize exposure. Only centres with proper equipment and trained personnel should administer inhaled pentamidine. Refer to hospital policy. The National Institute of Occupational Safety and Health (NIOSH) removed pentamidine from the hazardous drug list in 2014.
There is little information regarding long term effects of aerosolized pentamidine on health care workers. There is documentation stating aerosolized pentamidine to be embryotoxic in animals. (Tsai, Boiano and Sweeney 1410). The risks involved in administration can be reduced significantly if one adheres to standard safety precautions; however, pregnant women should reduce their exposure as there is insufficient data on additional risks during pregnancy. Please refer to your institutional policies and guidelines regarding safe handling.
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Equipment and Materials |
Oxygen flowmeter with nipple adapter |
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Negative Pressure room or HEPA filter machine with private room |
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Respirgard II nebulizer system with mouthpiece and nose clips or appropriate size mask |
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Pentamidine (300 mg) prepared by pharmacy If under 5 years of age please consult with the tertiary center on dosage |
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Particulate N95 mask for staff staying in room with the patient |
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Stethoscope |
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Bronchodilator with nebulizer or aero-chamber |
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Personal protective equipment (PPE) as appropriate for hazardous agents |
Pentamidine Aerosolization with the Respirgard II Nebulizer System
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Procedure |
Rationale |
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1. |
Obtain a medical order for pentamidine inhalation treatment and a bronchodilator. |
Risk of bronchospasm or cough. Patients who exhibit signs of cough or bronchospasm may benefit from inhaled bronchodilator prior to pentamidine treatment. |
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2. |
Explain procedure to patient including personal protective equipment. Also explain the need to limit the number of disconnections and the procedure to use in case the patient starts coughing. If using HEPA filter, place running filter machine in room 1 hour before starting treatment. |
HEPA filter must be running in room pre treatment. Private room, with door closed. Pentamidine should be administered under close supervision. |
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3. |
Obtain a careful respiratory history (eg. asthma, smoker). Assess and record patient’s pulse, respiratory rate and breathing. |
Bronchodilator should be readily available. |
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4. |
Wash hands. Put on personal protective equipment. Enter room. Door must remain closed. |
Staff using an N95 mask must be fit tested. Staff administering pentamidine must wear personal protective equipment. |
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5. |
Assemble the Respirgard II Nebulizer, connect extension tubing to oxygen flow meter or cylinder. Add the pentamidine solution to the medication chamber on the nebulizer. |
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6. |
Use a facemask or mouth piece and nose clips as per nursing assessment. Ask the patient to put on nose clips (if using) and to place the mouthpiece in their mouth and encourage them to breathe normally. Start flow meter. Use 5-8 LPM on flowmeter or 5-8 LPM on cylinder. Adjust flow to meet patients’ needs. |
Watch for a good seal around the mouthpiece, air expansion and normal breathing.
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7. |
Observe and assess respiratory status. Monitor for any signs of respiratory distress and administer bronchodilators as indicated. Turn off the flow and contact physician immediately if the patient develops wheezing or bronchospasm. |
Common side effects include cough, bronchospasm, metallic taste, burning sensation in back of throat, and fatigue. Some patients may require additional bronchodilators. |
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8. |
Instruct the patient to raise hand when requesting a break. Stop the flow meter before the patient removes the mouthpiece from their mouth. Do not restart flow meter until patient has mouthpiece back in their mouth. |
Treatment will take approximately 15 minutes. |
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9. |
At the end of the procedure, stop the flow meter before the patient removes the mouthpiece from their mouth. Instruct patient to rinse mouth and wash hands prior to leaving the room. Keep the HEPA filter running with the door closed. Discard the nebulizer, PPE and medication syringe in the cytototxic waste bin.
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Staff should not enter the room without PPE until 60 minutes after the treatment is completed. Housekeeping must wear gloves when cleaning but do not need to wear respiratory protection. Use wet method when cleaning to avoid creating dust. Housekeeping may clean the room 1.5 hours after the last procedure. Leave HEPA filter running with door closed for 60 minutes post treatment. |
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10. |
Assess pulse and respiratory rate. |
Observe for respiratory distress. |
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11. |
Document treatment and observations in the patient’s medical records chart. |
First Aid Measures
For eye or mucous membrane splashes of contact with pentamidine, immediately flush contaminated area with running water for at least 15 minutes. Obtain medical attention.
For skin contact with pentamidine, remove highly contaminated clothing and flush contaminated skin with running water for 15 minutes. Obtain medical attention.
For accidental inhalation of pentamidine, leave the area and obtain medical attention.
Document all exposures as per hospital policy.
References
- Beach JR, Campbell M, Andrew DJ. Exposure to health care worker to pentamidine isethionate. Occupational. Medicine 1999; 49: 243-245.
- British Occupational Hygiene Society. Pentamidine. Control of Substances Hazardous to Health (COSHH) Guidance 2006 Jun; Guidance note 0306.
- Critical Care Medicine Department, National Institutes of Health, Warren G. Magnuson Clinical Centre. Pentamidine aerosolization with the Respirgard II Nebulizer System.
- ISSA International Section on the Prevention of Occupational Risks in Health Services, Occupational risk prevention in aerosol therapy (pentamidine).
- NIOSH [2014]. NIOSH list of antineoplastic and other hazardous drugs in healthcare settings 2014. By Connor TH, MacKenzie BA, DeBord DG, Trout DB, O’Callaghan JP.. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2014-138 (Supersedes 2012-150).retrieved from : http://www.cdc.gov/niosh/docket/archive/pdfs/NIOSH-233/0233-2014-138ListofAntineoplastic2014.pdf
- Occupational Safety & Health Administration (OSHA) Archive, Hazardous medications Retrieved from http://www.osha.gov/archive/oshinfo/priorities/medication.html
- Sick Kids, Toronto. Policies and Drug Information for Nurses, Aerosol administration of Pentamidine. 2005 Feb.
- Tsai, R., Boiano, J., Steege, A., & Sweeney, M. (2015). Precautionary Practices of Respiratory Therapists and Other Health-Care Practitioners Who Administer Aerosolized Medications. Respiratory Care, 60(10), 1409-1417. doi:10.4187/respcare.03817
Primary author Ms. Patti Bambury, Grand River Hospital, Kitchener with input from Ms. Ursula DeBono, Windsor Regional Hospital, Windsor, Ms. Denise Reniers, Children’s Hospital, London Health Sciences Centre and Mr. John Wiernikowski, McMaster Children’s Hospital, Hamilton Health Sciences Centre, Hamilton. Reviewed by POGO Satellite Manual Review Nursing Group, 2016 and the POGO Satellite Manual Review Pharmacy Working Group, 2016.