Respiratory procedures: Use of nasal sprays in allergic rhinitis
Allergic rhinitis (AR) is a symptomatic nasal disorder induced by an Immunoglobulin E (IgE) mediated inflammation a…
VOL: 103, ISSUE: 37, PAGE NO: 24
Dave Burns, MSc, RGN, Cert Ed, RNT, is national training manager, Respiratory Education UK, University Hospital Aintree, Liverpool
Allergic rhinitis (AR) is a symptomatic nasal disorder induced by an Immunoglobulin E (IgE) mediated inflammation after the membranes lining the nose are exposed to allergens. It is classified based on the pattern of symptoms - those occurring on fewer than four days a week or lasting for no longer than four weeks are intermittent, and those present more than four days of the week or more than four weeks are persistent. Symptoms may be mild, with little impact on daily activities, or moderate/severe, when they may disturb sleep and interfere with everyday activities.
Incidence of AR has increased threefold in the UK over the last 20 years (Royal College of Physicians, 2003). In a survey of 1,000 people with AR, 49% experienced problems in work/school, 76% reported limitations in social/outdoor activities and 85% reported sleep problems (Allergy UK, 2005).
Conventionally, first-line treatment uses oral antihistamines, with second-generation drugs such as ceterizine or loratadine being seen as preferable, generally because of their improved safety profile.
Following on from this is the addition of topical treatments like intranasal corticosteroids (INCs) such as fluticasone, mometasone and beclometasone. These are administered via nasal spray and are highly effective in controlling symptoms. Mygind et al (2001) describe the actions of corticosteroids in detail.
A number of ways of producing therapeutic effects is possible but the end result is reduced inflammation. According to Price et al (2006) INCs are the most effective class of medications for treating AR and have a good safety profile. Other nasal preparations, such as cromones and antihistamines, are less effective and require multiple doses, while newer INCs, such as fluticasone and mometasone, have a daily dosing regimen.
Anecdotally, many patients report poor control of AR despite using INCs regularly - often due to poor technique. This article explains the main principles for correct use of nasal sprays in general. As there are minor differences between devices, patients should be advised to read the instructions supplied with their device thoroughly.
To prime the spray before use, remove the cap and activate the device with the thumb on the base and the index and second fingers on the collar. Press the collar repeatedly until the solution is emitted as a fine spray. This may take up to 10 depressions (Fig 1).
Repriming is only usually necessary if the device is not used for some time. If this is the case, the same procedure should be followed, although it should be noted that fewer depressions will be required.
Users should be told of the number of sprays in their device and advised to obtain a replacement before their current one runs out. For example, if a device contains 60 sprays, a patient using two sprays per day (one per nostril) will need a new device after 30 days’ use.
Patients should be taught the procedure below when prescribed an INC:
- Cleanse the nose before using the spray (Fig 2). Patient information leaflets advise blowing the nose, but manual cleansing may also be required as the drug needs to come into contact with the nasal mucosa.
- Sit upright with the head slightly forward and, using a forefinger, gently close a nostril.
- Insert the nozzle into the open nostril, pointing centrally, or slightly to the outer wall.
- Avoid spraying directly onto the medial septal wall as the mucosa here is much thinner and liable to break down resulting in epistaxis. In extreme cases septal perforation may occur - this seems to be more common in young women.
- Some authorities advocate using the left hand for the right nostril and vice versa (Fig 3) as this helps avoid over-deposition of drug on the medial septal wall.
- Gently inhale through the nostril being treated, depressing the collar of the device.
- It is vital to avoid ‘over-zealous sniffing’ as this will lead to the drug being inhaled away from the nose and into the posterior cavity, where it will trickle down the pharynx, leading to an unpleasant taste. This, coupled with the resulting lack of effect, may lead to non-adherence.
- Repeat with the other nostril (Fig 4).
- As the drug is delivered in a fine spray, ‘run off’ is minimal, but if the patient feels the need to sniff, this should be a gentle one.
- If two doses are needed for each nostril it may be helpful to alternate after each dose.
- Wipe the nozzle clean and replace the cap (Fig 5).
It is important to advise patients that it may take 2-3 days to see any benefit and that they should maintain treatment even when they have achieved good control. If treatment is stopped while the patient is still exposed to an allergen (such as during the hayfever ‘season’) the symptoms will quickly return.
The nozzle should be removed weekly and washed in warm water (Fig 6). It should then be dried before being replaced.
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This article has been double-blind peer-reviewedProfessional responsibilities
This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.