A nurse working in a pulmonary ward receives an order to give a patient two puffs of salmeterol, and two puffs of beclomethasone by a metered dose inhaler. What is the correct way of administering the medication?

Appeared in: DSSSB October 2024

Explanation

Salmeterol is a long-acting beta-2 agonist (LABA), a type of bronchodilator that works by relaxing airway smooth muscle to open the bronchi and bronchioles.
Beclomethasone is an inhaled corticosteroid (ICS) that reduces inflammation in the airways.
The established clinical practice is to administer the bronchodilator (salmeterol) before the corticosteroid (beclomethasone).
This sequence, often remembered by the mnemonic 'B before C' (Bronchodilator before Corticosteroid), ensures the airways are maximally dilated, allowing the anti-inflammatory steroid to reach deeper into the lungs.
A waiting period of about 5 minutes between the two different medications allows the bronchodilator to achieve its full effect.

Option B: Administering the corticosteroid (beclomethasone) first is less effective. If the airways are constricted, the steroid medication cannot penetrate deeply into the lungs and will deposit in the larger airways, reducing its therapeutic effect.
Option C: Alternating puffs is an incorrect procedure. The full prescribed dose of the bronchodilator should be administered first to achieve adequate bronchodilation before the corticosteroid is given.
Option D: This option is incorrect for two reasons: the corticosteroid is administered before the bronchodilator, and the medications are alternated puff-by-puff. Both actions contradict standard administration guidelines.

Clinical Relevance

Nursing practice connection: Use the key finding related to Pharmacology: Administration of Multiple Inhaled Medications to guide bedside assessment, documentation, and the next nursing action.
Correct administration technique is vital for managing chronic respiratory conditions like asthma and COPD. It directly impacts medication efficacy and patient outcomes, helping to prevent exacerbations.
Patient education is a core nursing responsibility. The nurse must teach the patient the correct sequence, the rationale for it ('B before C'), timing between puffs and medications, and the importance of rinsing the mouth after using corticosteroids to prevent oral candidiasis (thrush).
What if the patient is using a combination inhaler (e.g., Advair, which contains both fluticasone and salmeterol)? In this case, the medications are delivered simultaneously in a fixed-dose combination, and the sequencing issue is eliminated. The nurse should still teach the patient to rinse their mouth after use because it contains a corticosteroid.

How to Approach the Question

First, identify the drug classes of the medications mentioned in the question. Recognize salmeterol as a bronchodilator and beclomethasone as a corticosteroid.
Recall the fundamental pharmacological principle for administering these two classes of inhaled medications together.
Apply the mnemonic 'B before C': Bronchodilator first, then Corticosteroid.
Understand the rationale: The bronchodilator opens the airways, which allows the corticosteroid to travel deeper into the lungs and be more effective.
Evaluate the options based on this principle. Option A follows the correct sequence.
Eliminate the other options as they either reverse the sequence or suggest an incorrect procedure like alternating puffs.

Concept Tested & Keywords

Concept Tested: Pharmacology: Administration of Multiple Inhaled Medications
Stem keywords: salmeterol, beclomethasone, metered dose inhaler, administering medication
Lead-in keywords: correct way
Clinical cues: The care setting changes urgency, monitoring level, and the expected nursing action.
Negative lead-in flag: false

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E6 Pharmacology Nursing Lilley 11e Part 1 p. 322-323

E6 Pharmacology Nursing Lilley 11e Part 2 pp. 277-279, 278-280

Practise the full DSSSB October 2024

Attempt every question from this paper in a timed mock, then review the full solution for each one.