POGO

icon-facebook

POGO Satellite Manual

4.2 Pentamidine Administration

4.2.1 Inhaled Pentamidine

Download Word version
Download PDF version

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 trained on the safe handling and administration of pentamidine may administer aerosolized pentamidine to the patient for the prevention of pneumocystis jiroveci (formerly carinii) pneumonia (PJP or PCP). 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 used to help prevent the growth of PJP, 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.

Inhaled 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 use of this special nebulization system. The standard dose of administration 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 specialized childhood cancer programs conduct this procedure in a HEPA-filtered exhaust containment booth. This booth should be serviced and certified every 12 months. Centres without a containment booth should use a negative pressure room. If you do not have a negative pressure room, administer this procedure in a single room and use a portable HEPA filter.

Pediatric patients require a pre-treatment nursing assessment. Ensure age and cooperation level of patient are congruent with ability to receive inhaled pentamidine. The first dose of inhaled pentamidine should be administered at the specialized childhood cancer centre. It is important to know whether the patient tolerated the procedure and if a bronchodilator was required.

Do not administer pentamidine to pregnant patients, unless clearly indicated. If overexposed to pentamidine, staff may experience irritation of the conjunctivae or respiratory system, or respiratory or skin allergies. For this reason, staff must administer pentamidine using all appropriate precautions (e.g., containment booth and HEPA filtration system, personal protective equipment) to minimize exposure. Only centres with proper equipment and trained personnel should administer inhaled pentamidine.

Please refer to your institutional policies and guidelines regarding safe handling.

Equipment and Materials

  • Oxygen flowmeter with nipple adapter
  • Negative pressure room or HEPA filter machine with private room
  • Respirgard II Nebulizer system with mouthpiece and nose clips or appropriate size mask
  • Pentamidine (300 mg) prepared by pharmacy
    • Note: If patient under 5 years of age, please consult with the specialized childhood cancer program on dosage.
  • Particulate N95 mask for staff staying in room with the patient
  • Stethoscope
  • Bronchodilator with nebulizer or aero-chamber
  • Plugs (optional – should be considered for younger children to ensure mouth breathing during the procedure)
  • Personal protective equipment (PPE): Nitrile gloves rated for use with hazardous agents, N95 respirator that you have been fit-tested with, chemo gown and indirect vented chemical splash goggles
  • A current Safety Data Sheet (SDS) for pentamidine

Pentamidine Aerosolization with the Respirgard II Nebulizer System

ProcedureRationale
1.Obtain a medical order for pentamidine inhalation treatment and a bronchodilator if the patient requires one.Risk of bronchospasm or cough. Patients who exhibit signs of cough or bronchospasm may benefit from inhaled bronchodilator prior to pentamidine treatment.
2.Explain procedure to patient, including the use of PPE and procedure that will be followed if the patient starts coughing. If using HEPA filter, place running filter machine in room 1 hour before starting the treatment.Pentamidine should be administered under close supervision. HEPA filter must be running in room pre- treatment. Private room, with door closed.
3.Obtain a careful respiratory history (e.g., asthma, smoker). Assess and record patient’s pulse, respiratory rate and work of breathing.Bronchodilator and aerochamber or nebulizer should be readily available.
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 PPE.
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. 
6.Use a facemask or mouth piece and nose clips as per nursing assessment. Ask the patient to put on nose plugs (if using) and to place the mouthpiece in their mouth. Start flow meter. Use 5–8 LPM on flowmeter or 5–8 LPM on cylinder. Adjust flow to meet patient’s needs. Encourage the patient to breathe normally.Watch for a good seal around the mouthpiece, air expansion and normal breathing.  
7.Observe and assess respiratory rate, coughing, signs of increased work of breathing and bronchospasm during administration. Monitor for any signs of respiratory distress and administer bronchodilators as indicated. Turn off the flow meter 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.
8.Instruct the patient to raise their hand when requesting a break. Stop the flow meter before the patient removes the mouthpiece from their mouth. Do not restart the flow meter until patient has mouthpiece back in their mouth.Treatment will take approximately 15 minutes.
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 for 60 minutes post-treatment. Discard the nebulizer system, PPE and medication syringe in the cytototoxic waste bin.
10.Assess pulse and respiratory rate.Observe for respiratory distress.
11.Document treatment and observations in the patient’s medical records chart. 
12.Housekeeping staff may clean the room 1.5 hours after the last procedure.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.

First Aid Measures

For eye or mucous membrane splashes or 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.

Report and document all exposures as per hospital policy.

This guidance document was developed by Ms. Patti Bambury, Grand River Hospital, Ursula DeBono, Windsor Regional Hospital, Ms. Denise Reniers, Children’s Hospital, London Health Sciences Centre and Mr. John Wiernikowski, McMaster Children’s Hospital, Hamilton Health Sciences. Reviewed in consultation with Ms. Christina McCauley, POGO/The Hospital for Sick Children and Ms. Diana Masse and Ms. Mary Jo De Courcy, Children’s Hospital, London Health Sciences Centre based on the sources below.

References

  1. Beach JR, Campbell M, Andrew DJ. Exposure to health care worker to pentamidine isethionate. Occupational Medicine 1999; 49: 243-245.
  2. British Occupational Hygiene Society. Pentamidine. Control of Substances Hazardous to Health (COSHH) Guidance 2006 Jun; Guidance note 0306.
  3. Critical Care Medicine Department, National Institutes of Health, Warren G. Magnuson Clinical Centre. Pentamidine aerosolization with the Respirgard II Nebulizer System.
  4. ISSA International Section on the Prevention of Occupational Risks in Health Services, Occupational risk prevention in aerosol therapy (pentamidine). Retrieved October 26, 2021 from https://ww1.issa.int/sites/default/files/documents/publications/2-_Consensus_Paper_Aerosol_Therapy_en-29196.pdf.
  5. The Hospital for Sick Children, Toronto.  Policies and Procedures, Aerosol administration of Pentamidine.
Disclaimer: Source Accuracy

You are welcome to download and save a local copy of this document in the Word and/or PDF formats provided. As the POGO Satellite Manual is subject to ongoing revisions and updates by POGO, we recommend you regularly check the online version posted at https://www.pogo.ca/satellite-manual/ to ensure you have the most up-to-date content. In the event of any inconsistency between the content of a local copy and the online version of the POGO Satellite Manual, the content of the online version shall be considered correct. Please see also the POGO Satellite Manual Disclaimer.

Record of Updates
Version NumberDate of EffectSummary of Revisions
12/4/2022Original version posted.
4.2.2 Intravenous Pentamidine
Back to Top

In this Section

  • 1.1 History and Overview
  • 1.2 Acknowledgements
  • 1.3 Committees and Working Groups
  • 1.4 POGO Satellite Manual Disclaimer
  • 2.1 Principles of POGO Satellite Clinic Care
  • 2.2 Eligible Patients
    • 2.2.1 Children Eligible for Chemotherapy Administration in a POGO Satellite Clinic
    • 2.2.2 Children Eligible for the Management of Complications in a POGO Satellite Clinic
    • 2.2.3 Children Eligible for Supportive Care in a POGO Satellite Clinic
  • 2.3 Scope of POGO Satellite Clinic Practice
  • 2.4 Expanded POGO Satellite Clinic Practice
  • 3.1 Safe Handling, Administration and Disposal of Chemotherapy Agents
    • 3.1.1 Personal Protective Equipment
    • 3.1.2 Preparation, Transport and Storage
    • 3.1.3 Administration of IV Hazardous Drugs
    • 3.1.4 Administration of Oral Hazardous Drugs
    • 3.1.5 Disposal of Equipment/Personal Protective Equipment used to Administer Hazardous Drugs
    • 3.1.6 Safe Handling for Pharmacy
    • 3.1.7 References
  • 3.2 Accidental Exposure/Spills
  • 3.3 Extravasation Management
    • 3.3.1 Prevention and Management of Extravasations
    • 3.3.2 Antidotes and Treatments for Extravasation
    • 3.3.3 Sample Extravasation Documenting Tool
    • 3.3.4 References
  • 3.4 Injecting SC Medication Via an Insuflon
  • 3.5 Chemotherapy Administration Reference List
  • 3.6 Central Venous Catheter Care
  • 3.7 Chemotherapy Quick Reference
    • 3.7.1 Rapid Hydration
    • 3.7.2 Provider Guide: Prevention and Management of Irinotecan-Induced Diarrhea
    • 3.7.3 Capizzi Methotrexate
    • 3.7.4 Erwinia Asparaginase
  • 4.1 Management of Fever and Neutropenia
    • 4.1.1 Routine Order Sample Sheet
    • 4.1.2 Sample Fever Cards
    • 4.1.3 Criteria for low-risk designation. Risk categorization refers to risk of bacteremia and serious complications, including mortality.
  • 4.2 Pentamidine Administration
    • 4.2.1 Inhaled Pentamidine
    • 4.2.2 Intravenous Pentamidine
  • 4.3 Antiemetics
  • 4.4 Treatment of Varicella-Zoster Infections
  • 4.5 Immunization of Children with Cancer
  • 4.6 Transfusion
  • 4.7 Clinical Circumstances that Warrant Consultation with the Specialized Childhood Cancer Program
  • 5.1 Palliative Care Overview
  • 5.2 Communication
  • 5.3 Settings of Care
  • 5.4 Symptom Management
  • 5.5 End of Life
  • 5.6 When a Child Dies at the POGO Satellite Clinic
  • 5.7 Appendix: Sample Bereavement Materials
    • 5.7.1 Reconciling Your Grief
    • 5.7.2 Funeral Arrangement Checklist
    • 5.7.3 Helping Children Who Grieve
    • 5.7.4 Coping with the Holidays
    • 5.7.5 The Grief Experience
  • 5.8 References
  • 6.1 Goals and Objectives
  • 6.2 Participant Site Selection
    • 6.2.1 Tertiary Hospital Site Selection
    • 6.2.2 Community Hospital Site Selection
  • 6.3 POGO’s Roles
    • 6.3.1 PHIPA, Privacy and Research
  • 6.4 Funding
    • 6.4.1 Funding Support for Tertiary Hospital Activity
    • 6.4.2 Funding Support for Community Hospital Activity
  • 6.5 Infrastructure and Formal Requirements
    • 6.5.1 Specialized Childhood Cancer Program Partners’ Role in the POGO Satellite Program
    • 6.5.2 POGO Satellite Clinic Partners’ Role in the POGO Satellite Program
  • 7.1 Preamble
  • 7.2 Investigator Responsibilities
  • 7.3 Training Requirements
    • 7.3.1 General Training for Conduct of Research
    • 7.3.2 Protocol-Specific Training
  • 7.4 Research Activities That May Be Completed in POGO Satellite Clinics Under Supervision of DSI
  • 7.5 Research Activities to be Completed in Specialized Childhood Cancer Programs Only
  • 7.6 Recognition and Reporting of Adverse Events (AEs)
  • 7.7 Data Transfer
  • 7.8 Pharmacy Drug Accountability
  • 7.9 Site Inspections and Quality Assurance
  • 8.1 Pediatric Oncology Shared Care Initial Data Transfer Sheet
  • 9.1 POGO Satellite Clinic Preparedness Checklist
  • 9.2 POGO Satellite Clinic Quality Assurance Checklist
Back to table of contents
Search our Manual
Have a question?
Contact us at: satellite@pogo.ca
  • About Us
    • Our Mission and Vision
    • Childhood Cancer Care Plan
    • POGO Land Acknowledgement
    • Diversity, Equity, Inclusion
    • Our Board
    • Our Partners
    • Our Donors
    • Privacy
    • Accessibility
    • Reports
    • Newsroom
    • Job Opportunities
    • Staff List
  • Programs & Support
    • Patient Care Programs
    • Financial Assistance
    • Survivor Care
    • Cancer Resources
    • Inspiring Stories
    • Clinical and Program Advisory Committees
  • Education
    • POGO Satellite Education Day
    • POGO Virtual Education
    • Indigenous Resource Guide
    • All Education Events & Conferences
  • Healthcare Practice
    • Pediatric Oncology Nursing
    • Clinical Practice Guidelines
    • POGO Satellite Manual
  • Research & Data
    • 2020 POGO Surveillance Report
    • POGO Research Unit
    • POGONIS – Childhood Cancer Database
    • Data Reports
    • Data Requests
  • Get Involved
    • Pajamas and Pancakes
    • Birthday Parties for POGO
    • Events
    • Volunteer
  • Ways to Give
    • Donate
    • Monthly Donations
    • Gifts of Stock and Securities
    • Become a Corporate Partner
    • Gifts in Honour/Memory
    • Legacy Gifts
    • Shop Online/Earn Cash Back

©2022 Pediatric Oncology Group of Ontario

480 University Avenue, Suite 1014 | Toronto, Ontario, M5G 1V2, Canada | Charitable Registration Number: 871067245RR0001 |
1-855-FOR POGO (367-7646) | Contact Us | Website Privacy Policy | Website Disclaimer | Satellite Manual Disclaimer |