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Clinical Procedures - Sengstaken-Blakemore Tube Insertion
Indications
• Life-threatening variceal bleeding where facilities for endoscopy are not available or pending endoscopic therapy
• Life-threatening variceal bleeding where other modalities to control bleeding have failed.
Contraindications
• Variceal bleeding has ceased or significantly slowed
• Recent surgery to the GO]
• Known esophageal stricture (s).
Risks
• Mucosal necrosis due to inadvertent traction
• Oesophageal perforation. This may be due to a gastric balloon being inflated within the esophagus or can occur secondary to over- or prolonged inflation of the esophageal balloon
• Aspiration of fluid into the respiratory tract. The greatest risk occurs during insertion
• Asphyxiation due to superior migration of the tube and balloons. See last 'procedure tip' below.
Procedure Tips
• The tube can be used as a measure to control bleeding for about
12-18 hours. Generally, it should not be left in place for >24 hours
• Frequent aspirations from the gastric port are needed to assess the status of bleeding
• The tube has to remain in traction at the gastric balloon which will decompress the varices. However, direct pressure from the tube can cause mucosal ulceration. Examine frequently to ensure that excessive force is not being exerted
• If the balloons migrate superiorly, airway obstruction may occur. In this instance, as an emergency measure, the tube can be quickly cut with a pair of scissors and removed. Keep a pair of scissors handy.
This should be performed only by senior medical staff in close liaison with an anaesthetist and, ideally, with endotracheal intubation especially in agitated patients and those with hepatic encephalopathy.
• The threshold to perform endotracheal intubation should be low, as the risk of regurgitation and aspiration is extremely high. To minimize this risk, perform nasogastric lavage and maximal stomach evacuation prior to procedure.
Equipment
• Gloves, gown, and goggles
• Saline flush
• 2 x 50mL syringe.
• Local anaesthetic spray
• Sengstaken-Blakemore tube (usually kept in refrigerator to increase its stiffness)
• Lubricant jelly (e.g. Aquagel®
• Basin with sterile water
• Suction equipment
• Sphygmomanometer for pressure monitoring.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure to the patient, and obtain informed consent
• Position the patient at 45°
• Administer anaesthetic throat spray to the oropharynx
• Check the balloons in the tube for air leak by inflating them with an air-filled syringe and immersing in a basin of water.
Air leak is indicated by air bubbles appearing
• Deflate the balloons
• Apply lubricant over the tip of the tube and advance it through the oral cavity slowly until it crosses the gastro-oesophageal junction (GOJ):
• The GOJ is generally 38-42cm from the nostril so advancement of the tube 55-60cm usually positions the tip within the stomach
• Withdraw if the patient becomes breathless
• Inflate the gastric (not esophageal) balloon with 50mL air
• At this stage an abdominal radiograph may be performed to confirm the position of the tube in the stomach
• Once position is confirmed, inflate the gastric balloon to a total volume of 250mL air
• Pull gently on the tube until resistance is felt
• Secure with tape near the mouth with gauze pads, maintaining traction and tie the tube to a 500mL bag of saline. A pulley (e.g. a drip stand) is helpful in maintaining traction
• Mark the tube near the mouth which will serve as an indicator to whether the tube has migrated later
• Flush the gastric port with normal saline and aspirate at frequent intervals until it is clear, which indicates that bleeding has ceased
• • If bleeding continues, inflate the esophageal balloon with 40mL air and monitor the pressures using the sphygmomanometer at frequent intervals
• D After 12 hours of traction, relax the tension and push the tube into the stomach. If there is evidence of further bleeding, the gastric balloon can be re-inflated and traction re-applied with a view to repeat therapeutic endoscopy
• D During extubation (usually after 10-12 hours depending on clinical condition), deflate the gastric balloon first then the esophageal balloon and withdraw the tube slowly.
Documentation
• Date, time, indication, informed consent obtained
• Those present, including anaesthetic support
• How many passes?
• Volume balloon inflated to and level of tube insertion
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Life-threatening variceal bleeding where facilities for endoscopy are not available or pending endoscopic therapy
• Life-threatening variceal bleeding where other modalities to control bleeding have failed.
Contraindications
• Variceal bleeding has ceased or significantly slowed
• Recent surgery to the GO]
• Known esophageal stricture (s).
Risks
• Mucosal necrosis due to inadvertent traction
• Oesophageal perforation. This may be due to a gastric balloon being inflated within the esophagus or can occur secondary to over- or prolonged inflation of the esophageal balloon
• Aspiration of fluid into the respiratory tract. The greatest risk occurs during insertion
• Asphyxiation due to superior migration of the tube and balloons. See last 'procedure tip' below.
Procedure Tips
• The tube can be used as a measure to control bleeding for about
12-18 hours. Generally, it should not be left in place for >24 hours
• Frequent aspirations from the gastric port are needed to assess the status of bleeding
• The tube has to remain in traction at the gastric balloon which will decompress the varices. However, direct pressure from the tube can cause mucosal ulceration. Examine frequently to ensure that excessive force is not being exerted
• If the balloons migrate superiorly, airway obstruction may occur. In this instance, as an emergency measure, the tube can be quickly cut with a pair of scissors and removed. Keep a pair of scissors handy.
This should be performed only by senior medical staff in close liaison with an anaesthetist and, ideally, with endotracheal intubation especially in agitated patients and those with hepatic encephalopathy.
• The threshold to perform endotracheal intubation should be low, as the risk of regurgitation and aspiration is extremely high. To minimize this risk, perform nasogastric lavage and maximal stomach evacuation prior to procedure.
Equipment
• Gloves, gown, and goggles
• Saline flush
• 2 x 50mL syringe.
• Local anaesthetic spray
• Sengstaken-Blakemore tube (usually kept in refrigerator to increase its stiffness)
• Lubricant jelly (e.g. Aquagel®
• Basin with sterile water
• Suction equipment
• Sphygmomanometer for pressure monitoring.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure to the patient, and obtain informed consent
• Position the patient at 45°
• Administer anaesthetic throat spray to the oropharynx
• Check the balloons in the tube for air leak by inflating them with an air-filled syringe and immersing in a basin of water.
Air leak is indicated by air bubbles appearing
• Deflate the balloons
• Apply lubricant over the tip of the tube and advance it through the oral cavity slowly until it crosses the gastro-oesophageal junction (GOJ):
• The GOJ is generally 38-42cm from the nostril so advancement of the tube 55-60cm usually positions the tip within the stomach
• Withdraw if the patient becomes breathless
• Inflate the gastric (not esophageal) balloon with 50mL air
• At this stage an abdominal radiograph may be performed to confirm the position of the tube in the stomach
• Once position is confirmed, inflate the gastric balloon to a total volume of 250mL air
• Pull gently on the tube until resistance is felt
• Secure with tape near the mouth with gauze pads, maintaining traction and tie the tube to a 500mL bag of saline. A pulley (e.g. a drip stand) is helpful in maintaining traction
• Mark the tube near the mouth which will serve as an indicator to whether the tube has migrated later
• Flush the gastric port with normal saline and aspirate at frequent intervals until it is clear, which indicates that bleeding has ceased
• • If bleeding continues, inflate the esophageal balloon with 40mL air and monitor the pressures using the sphygmomanometer at frequent intervals
• D After 12 hours of traction, relax the tension and push the tube into the stomach. If there is evidence of further bleeding, the gastric balloon can be re-inflated and traction re-applied with a view to repeat therapeutic endoscopy
• D During extubation (usually after 10-12 hours depending on clinical condition), deflate the gastric balloon first then the esophageal balloon and withdraw the tube slowly.
Documentation
• Date, time, indication, informed consent obtained
• Those present, including anaesthetic support
• How many passes?
• Volume balloon inflated to and level of tube insertion
• Any immediate complications
• Signature, printed name, and contact details.
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Clinical Procedures – Basic Airway Manoeuvres
The following manoeuvres are performed with the patient lying supine and the attender positioned above the head.
The aim is to prevent the flaccid tongue from falling back and causing the epiglottis or tongue itself to occluding the airway.
These can be performed with no equipment.
Head Tilt
• Place your hands on the forehead and tilt the head backwards, extending the neck.
Chin Lift
• Place 2 fingertips below the mental protuberance of the mandible, with thumb in front
• Draw the mandible anteriorly.
Head tilt and chin lift are usually performed together.
• Head tilt and chin lift are not suitable if there is any suspicion of cervical spinal injury. Jaw thrust alone should be used in this situation.
Jaw Thrust
• Place your fingertips behind the angle of the mandible.
• The base of the thenar eminence of each hand should be rested on the cheek bones
• Use your fingers to pull the mandible anteriorly, whilst using your thumbs to open the mouth
• If performed with a mask, the thenar eminence may be used to maintain a good seal.
Procedure Tips
• After each manoeuvre, check for success
• It is worthwhile practicing these skills on resuscitation dummies prior to having to do them in real life!
• Use the above manoeuvres in conjunction with face masks or bag-valve mask ventilation.
The following manoeuvres are performed with the patient lying supine and the attender positioned above the head.
The aim is to prevent the flaccid tongue from falling back and causing the epiglottis or tongue itself to occluding the airway.
These can be performed with no equipment.
Head Tilt
• Place your hands on the forehead and tilt the head backwards, extending the neck.
Chin Lift
• Place 2 fingertips below the mental protuberance of the mandible, with thumb in front
• Draw the mandible anteriorly.
Head tilt and chin lift are usually performed together.
• Head tilt and chin lift are not suitable if there is any suspicion of cervical spinal injury. Jaw thrust alone should be used in this situation.
Jaw Thrust
• Place your fingertips behind the angle of the mandible.
• The base of the thenar eminence of each hand should be rested on the cheek bones
• Use your fingers to pull the mandible anteriorly, whilst using your thumbs to open the mouth
• If performed with a mask, the thenar eminence may be used to maintain a good seal.
Procedure Tips
• After each manoeuvre, check for success
• It is worthwhile practicing these skills on resuscitation dummies prior to having to do them in real life!
• Use the above manoeuvres in conjunction with face masks or bag-valve mask ventilation.
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Clinical Procedures - Oropharyngeal (Guedel) airway
A stiff tube with a fixed curvature is inserted through the mouth. A flange limits the depth of insertion.
• Use when the patient is semi-conscious.
Indications
• Airway compromise in the patient with reduced conscious level.
Contraindications
• Active gag reflex. Conscious patient.
Procedure
• Insert the airway initially with the curvature upwards
• Once inside the mouth, rotate it 180°
• Continue to insert, following the curvature of the tongue until the flange rests against the teeth or gums
• Ensure there is no gagging, snoring or vomiting and that air can move in and out freely.
Procedure Tips
• May be used for suction (size 10, 12, or 14 catheters).
• Insertion can be guided with a tongue depressor.
Airway Sizes
• Oropharyngeal airways come in many sizes and are colour-coded for convenience
• Select the correct size of airway for the patient by measuring it against the side of the patients face. The flange should sit at the corner of the patient's mouth and the tip at the angle of the jaw.
A stiff tube with a fixed curvature is inserted through the mouth. A flange limits the depth of insertion.
• Use when the patient is semi-conscious.
Indications
• Airway compromise in the patient with reduced conscious level.
Contraindications
• Active gag reflex. Conscious patient.
Procedure
• Insert the airway initially with the curvature upwards
• Once inside the mouth, rotate it 180°
• Continue to insert, following the curvature of the tongue until the flange rests against the teeth or gums
• Ensure there is no gagging, snoring or vomiting and that air can move in and out freely.
Procedure Tips
• May be used for suction (size 10, 12, or 14 catheters).
• Insertion can be guided with a tongue depressor.
Airway Sizes
• Oropharyngeal airways come in many sizes and are colour-coded for convenience
• Select the correct size of airway for the patient by measuring it against the side of the patients face. The flange should sit at the corner of the patient's mouth and the tip at the angle of the jaw.
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Clinical Procedures - Nasopharyngeal airway
A flexible tube is inserted through the nostril into the pharynx and is better tolerated than the oropharyngeal airway in semi-conscious patients.
Although there is a small flange at the end of the airway, a safety pin is usually inserted to prevent the device migrating into the patient's nose.
Indications
• Patients with reduced conscious level and/or airway compromise who will not tolerate an oropharyngeal airway (intact gag reflex).
Contraindications
• Known basal skull fracture (relative contraindication).
Procedure
• Lubricate the device
• Insert bevelled end into the wider nostril, passing it posteriorly and medially, aiming for the back of the opposite eyeball
• Use size 10 or 12 catheter for suction if required
• Advance until the flange is flush against the nostril.
Procedure Tips
• If insertion proves difficult, try the opposite nostril.
Airway sizes
• Nasopharyngeal airways come in several sizes; the size is usually stamped on the side
• Select the correct size for your patient by measuring the airway against the side of their face. The flange should lie at the patient's nostril and the tip at the tragus of the ear.
A flexible tube is inserted through the nostril into the pharynx and is better tolerated than the oropharyngeal airway in semi-conscious patients.
Although there is a small flange at the end of the airway, a safety pin is usually inserted to prevent the device migrating into the patient's nose.
Indications
• Patients with reduced conscious level and/or airway compromise who will not tolerate an oropharyngeal airway (intact gag reflex).
Contraindications
• Known basal skull fracture (relative contraindication).
Procedure
• Lubricate the device
• Insert bevelled end into the wider nostril, passing it posteriorly and medially, aiming for the back of the opposite eyeball
• Use size 10 or 12 catheter for suction if required
• Advance until the flange is flush against the nostril.
Procedure Tips
• If insertion proves difficult, try the opposite nostril.
Airway sizes
• Nasopharyngeal airways come in several sizes; the size is usually stamped on the side
• Select the correct size for your patient by measuring the airway against the side of their face. The flange should lie at the patient's nostril and the tip at the tragus of the ear.
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Clinical Procedures – Laryngeal Mask Airway
A laryngeal mask airway (LMA) is a tube with an inflatable cuff ('mask) around its base to create a seal around the laryngeal inlet.
• This does not prevent aspiration of stomach contents.
Indications
• Unconscious patient requiring ventilation.
Contraindications
• Conscious patient (absolute)
• Maxillofacial trauma
• Risk of aspiration
• >16 weeks pregnant.
Procedure
• Ensure that the cuff inflates and deflates satisfactorily
• For insertion, the mask should be completely deflated
• Deflate the cuff with a 20mL syringe. Lubricate the outer cuff with aqueous gel
• Gently extend the head and flex the neck (except in possible cervical trauma)
• Hold the LMA tubing near the cuff, like a pen
• With the mask facing down, pass along the under-surface of the palate until it reaches the posterior pharynx
• Guide the tube backwards and downwards (using a finger if necessary) until resistance is felt
• Remove your hand and fill the mask with the required amount of air (usually 20-30mL):
• The tube should lift out of the mouth slightly and the larynx is pushed forward if it is in the correct position
• Connect the bag-valve mask and ventilate
• Auscultate in both axillary regions to confirm ventilation
• Insert a bite block/Guedel airway next to the tube in case the patient bites down
• Secure in place with tape/ribbon.
A laryngeal mask airway (LMA) is a tube with an inflatable cuff ('mask) around its base to create a seal around the laryngeal inlet.
• This does not prevent aspiration of stomach contents.
Indications
• Unconscious patient requiring ventilation.
Contraindications
• Conscious patient (absolute)
• Maxillofacial trauma
• Risk of aspiration
• >16 weeks pregnant.
Procedure
• Ensure that the cuff inflates and deflates satisfactorily
• For insertion, the mask should be completely deflated
• Deflate the cuff with a 20mL syringe. Lubricate the outer cuff with aqueous gel
• Gently extend the head and flex the neck (except in possible cervical trauma)
• Hold the LMA tubing near the cuff, like a pen
• With the mask facing down, pass along the under-surface of the palate until it reaches the posterior pharynx
• Guide the tube backwards and downwards (using a finger if necessary) until resistance is felt
• Remove your hand and fill the mask with the required amount of air (usually 20-30mL):
• The tube should lift out of the mouth slightly and the larynx is pushed forward if it is in the correct position
• Connect the bag-valve mask and ventilate
• Auscultate in both axillary regions to confirm ventilation
• Insert a bite block/Guedel airway next to the tube in case the patient bites down
• Secure in place with tape/ribbon.
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Clinical Procedures – Basic Spirometry
Basic spirometry is a simple lung function test which can aid diagnosis of a number of conditions, but is primarily used to distinguish between restrictive and obstructive lung diseases.
Different spirometers vary in their operation, but most are now hand-held computerized devices with an easy-to-use interface, able to calculate normal values and print a spirometry report. The following describes the use of this device.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• The patient should be standing or sitting upright
° Input the data requested by the spirometer if appropriate: age, gender, and height
• Ask the patient to take a deep breath and wrap their lips around the mouthpiece, making an airtight seal
• Ask the patient to breathe out as hard and as long as possible until they feel they have completely emptied their lungs
• Three satisfactory breaths should be obtained:
• D The volume-time graph should be smooth, subsequent
FEV1 and FVC results should be within 100mL of each other
• Save and print the report.
Procedure Tips
• If the patient is having difficulty performing correctly, a brief demonstration often proves very useful
• Performing the test seated may be easier for elderly or infirm patients.
Documentation
• Record the FVC, FEV , the FEV/FVC ratio and relevant predicted values. Also document the quality and reproducibility of blows and whether pre- or post-treatment.
Key Values
• FEV: forced expiratory volume in the first second
• FVC: forced vital capacity (the total lung volume from maximum inspiration to maximum expiration, in forced exhalation).
Common patterns of abnormality
Obstructive
Although FVC may be reduced, FEV is much more reduced, hence the FEV/FVC ratio falls. It can also take much longer to fully exhale
Restrictive
The airway patency is not affected in restrictive lung conditions but the
FEV and FVC are reduced due to the restrictive picture
Basic spirometry is a simple lung function test which can aid diagnosis of a number of conditions, but is primarily used to distinguish between restrictive and obstructive lung diseases.
Different spirometers vary in their operation, but most are now hand-held computerized devices with an easy-to-use interface, able to calculate normal values and print a spirometry report. The following describes the use of this device.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• The patient should be standing or sitting upright
° Input the data requested by the spirometer if appropriate: age, gender, and height
• Ask the patient to take a deep breath and wrap their lips around the mouthpiece, making an airtight seal
• Ask the patient to breathe out as hard and as long as possible until they feel they have completely emptied their lungs
• Three satisfactory breaths should be obtained:
• D The volume-time graph should be smooth, subsequent
FEV1 and FVC results should be within 100mL of each other
• Save and print the report.
Procedure Tips
• If the patient is having difficulty performing correctly, a brief demonstration often proves very useful
• Performing the test seated may be easier for elderly or infirm patients.
Documentation
• Record the FVC, FEV , the FEV/FVC ratio and relevant predicted values. Also document the quality and reproducibility of blows and whether pre- or post-treatment.
Key Values
• FEV: forced expiratory volume in the first second
• FVC: forced vital capacity (the total lung volume from maximum inspiration to maximum expiration, in forced exhalation).
Common patterns of abnormality
Obstructive
Although FVC may be reduced, FEV is much more reduced, hence the FEV/FVC ratio falls. It can also take much longer to fully exhale
Restrictive
The airway patency is not affected in restrictive lung conditions but the
FEV and FVC are reduced due to the restrictive picture
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Clinical Procedures - Metered Dose Inhaler
Requires coordination to use effectively and lacks a dose counter. May be unsuitable for the very young, elderly, or those with arthritis affecting the hands.
How to use
• Take only one dose at a time
• Remove the cap and shake the inhaler several times
• Sit upright, breathe out completely
• Insert mouthpiece in mouth, sealing with lips
• Take a deep breath in; just after you begin to breathe in depress the canister whilst continuing to inhale:
• The canister should be pressed just after the start of inhalation, not before
• Inhale slowly and deeply
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Recover before taking the next dose and repeat above as necessary
• Replace cap.
Requires coordination to use effectively and lacks a dose counter. May be unsuitable for the very young, elderly, or those with arthritis affecting the hands.
How to use
• Take only one dose at a time
• Remove the cap and shake the inhaler several times
• Sit upright, breathe out completely
• Insert mouthpiece in mouth, sealing with lips
• Take a deep breath in; just after you begin to breathe in depress the canister whilst continuing to inhale:
• The canister should be pressed just after the start of inhalation, not before
• Inhale slowly and deeply
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Recover before taking the next dose and repeat above as necessary
• Replace cap.
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Clinical Procedures - Autohaler
This is a 'breath-actuated' inhaler, releasing a dose automatically as a breath is taken. No hand coordination is required. The priming lever, however, can prove difficult to use and requires priming before each dose.
How to use
• Remove cap and shake inhaler several times
• Prime by pushing the lever into the vertical position whilst keeping the inhaler upright
• Sit upright, breathe out completely, and insert mouthpiece, sealing with lips
• Inhale slowly and deeply:
• • Don't stop when the inhaler clicks
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Push lever down and allow time to recover before taking the next dose
• Once doses are taken, replace cap.
Procedure Tips
• Patients unable to operate the lever by hand may be able to use a hard surface such as the edge of a table for assistance
• Use inhaler only for the number of doses written on the label
This is a 'breath-actuated' inhaler, releasing a dose automatically as a breath is taken. No hand coordination is required. The priming lever, however, can prove difficult to use and requires priming before each dose.
How to use
• Remove cap and shake inhaler several times
• Prime by pushing the lever into the vertical position whilst keeping the inhaler upright
• Sit upright, breathe out completely, and insert mouthpiece, sealing with lips
• Inhale slowly and deeply:
• • Don't stop when the inhaler clicks
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Push lever down and allow time to recover before taking the next dose
• Once doses are taken, replace cap.
Procedure Tips
• Patients unable to operate the lever by hand may be able to use a hard surface such as the edge of a table for assistance
• Use inhaler only for the number of doses written on the label
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Clinical Procedures - Easi-breathe
Breath-actuated inhaler, as autohaler only primed by opening the cap hence this must be closed and opened again between successive doses.
How to use
• Shake the inhaler several times
• Hold upright and prime by opening the cap
• Sit upright, breathe out completely, and insert mouthpiece, sealing with lips:
• Make sure that your fingers are not covering the air holes at the top
• Inhale slowly and deeply
• © Don't stop when the inhaler puffs
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Close the cap, with the inhaler upright
• Recover before taking the next dose.
Procedure Tips
• It is essential to close and then open the cap between successive doses. This primes the inhaler
• Advise the patient not to dismantle the inhaler. Patients used to using MDIs may be tempted to take the top off and attempt to depress the canister manually.
Breath-actuated inhaler, as autohaler only primed by opening the cap hence this must be closed and opened again between successive doses.
How to use
• Shake the inhaler several times
• Hold upright and prime by opening the cap
• Sit upright, breathe out completely, and insert mouthpiece, sealing with lips:
• Make sure that your fingers are not covering the air holes at the top
• Inhale slowly and deeply
• © Don't stop when the inhaler puffs
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Close the cap, with the inhaler upright
• Recover before taking the next dose.
Procedure Tips
• It is essential to close and then open the cap between successive doses. This primes the inhaler
• Advise the patient not to dismantle the inhaler. Patients used to using MDIs may be tempted to take the top off and attempt to depress the canister manually.
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Clinical Procedures- Accuhaler
Dry powder device, superseding the Diskhaler and Rotahaler.
Has a dose counter. The several-step priming mechanism may be difficult for some to manage
How to use
• Hold the outer casing in one hand whilst pushing the thumb grip away, exposing the mouthpiece, until you hear a click
. With the mouthpiece towards you, slide the lever away from you until it clicks. The device is now primed
• Sit upright, breathe out completely and insert mouthpiece, sealing with lips
• Inhale quickly and deeply
• (In contrast to breath-actuated devices)
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• To close, pull the thumb grip towards you, hiding the mouthpiece in the cover, until you hear a click
• Recover before taking the next dose.
Procedure Tips
• The Accuhaler must be closed and re-primed between successive doses.
• The dose counter indicates how many doses are left.
Dry powder device, superseding the Diskhaler and Rotahaler.
Has a dose counter. The several-step priming mechanism may be difficult for some to manage
How to use
• Hold the outer casing in one hand whilst pushing the thumb grip away, exposing the mouthpiece, until you hear a click
. With the mouthpiece towards you, slide the lever away from you until it clicks. The device is now primed
• Sit upright, breathe out completely and insert mouthpiece, sealing with lips
• Inhale quickly and deeply
• (In contrast to breath-actuated devices)
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• To close, pull the thumb grip towards you, hiding the mouthpiece in the cover, until you hear a click
• Recover before taking the next dose.
Procedure Tips
• The Accuhaler must be closed and re-primed between successive doses.
• The dose counter indicates how many doses are left.
