Pre‐procedural considerations

Only negative‐pressure rooms or positive‐pressure lobbied rooms (which all have sufficient extraction) are to be used where ribavirin is administered via a nebulizer. During nebulized administration of the drug, entry to the room should be limited as far as is practically possible. A warning sign ‘Respiratory Isolation: Do Not Enter: Ribavirin Administration In Progress’ must be placed on the patient's door during the time that the Aiolos nebulizer is in operation to ensure that staff and visitors do not unknowingly enter the room. Signs should be available from the infection control team. If an appropriate room is not available, consideration should be given to delaying the use of nebulized ribavirin, and intravenous or oral administration may be considered.

Equipment

Ribavirin is administered via an aerosol generator such as the ICN small particle aerosol generator (SPAG) model. It is important to read the operator's manual for instructions prior to use (Valeant [113]).
The aerosol can be delivered to an infant oxygen hood from the aerosol generator. Administration by facemask or oxygen tent may be necessary if a hood cannot be employed. However, the volume of distribution and condensation area are larger in a tent and efficacy of this method of administering the drug has been evaluated in only a small number of patients. Ribavirin should not be administered with any other aerosol generating device or from the same reservoir as other aerosolized medications (Valeant [113]).
It is important to use the recommended drug concentration as recommended by the manufacturer of the aerosol generator.
Personal protective equipment is necessary to administer ribavirin. A filtering facepiece 2 (FFP2) mask, a disposable apron, gloves and fitting goggles are required (Figure 21.11).
image
Figure 21.11  Nurse wearing personal protective equipment (PPE) for the administration of ribavirin.

Assessment and recording tools

It is vital that patients are assessed for their suitability to be treated with ribavirin and that they have a good performance status. This is to ensure that they can safely be left alone for the 2‐hour administration of the drug.

Pharmacological support

It is recommended that pharmacy reconstitute ribavirin in a controlled environment with extraction facilities (COSHH [24]), however the drug can be drawn up with PPE in the patient's room if required out of hours.

Non‐pharmacological support

Thought should be given to the patient and their relatives as isolation is required during administration. Relatives should be advised not to enter the room during administration. This can often leave the patient feeling isolated and vulnerable; equally relatives should be kept regularly informed about when it is safe to enter the room so they can offer support to the patient (Ghosh et al. [44]).
Procedure guideline 21.4
Table 21.7  Prevention and resolution (Procedure guideline 21.4)
ProblemCausePreventionAction
Medication crystal formationRibavirin crystalsMake sure equipment is cleaned between doses and correctly assembled according to manufacturer's instructionsIf the crystal deposit exceeds 1 mm, rinse using sterile water or fit new tubing
There is little or no aerosol
The equipment is not correctly assembled
The flow meter is turned off, or is not fully adjusted
The equipment is dirty or clogged
The equipment is broken
Check equipment before use
Maintenance of equipment as recommended by the manufacturer
Reassemble equipment
Adjust the flow meter to administer the correct flow
Replace faulty components