CLINICAL
Intranasal Drug Delivery: An Alternative to Intravenous Administration in Selected Emergency Cases

https://doi.org/10.1016/j.jen.2004.01.006Get rights and content

Section snippets

Factors affecting nasal drug absorption

The percentage of medication that ends up in the bloodstream after administration is termed “bioavailability.” Intravenous medication is 100% bioavailable after administration. Oral medications are about 5% to 10% bioavailable because of gastrointestinal and hepatic destruction. Intranasal medication bioavailability varies from negligible to almost 100%.

If a drug molecule can cross the nasal mucosa, the primary factors influencing bioavailability are medication concentration and volume,

Intranasal medication delivery in the emergency department

A number of commonly used ED medications are effective when delivered intranasally. These medications include the synthetic opiates fentanyl and sufentanil for the treatment of acute pain; midazolam, for procedural sedation and for the treatment of seizures; naloxone, for opiate overdose; and topical anesthetics/vasoconstrictors for use prior to nasal intubation or nasogastric tube (NGT) placement or for the treatment of epistaxis (Table 2).

Pain control: intranasal opiates

Many patients who visit the emergency department fail to obtain adequate pain relief.4 One reason is the lack of a rapid, effective, painless method for pain control. Nasal opiates offer an effective, inexpensive solution. The synthetic opiates fentanyl and sufentanil are uniquely suited for transmucosal delivery because of their high lipid solubility and their high potency (100 to 1000 times more potent than morphine).2., 5., 6., 7. Sufentanil is probably the best opiate medication currently

Procedural sedation: intranasal opiates, benzodiazepines, and ketamine

Procedural sedation also can be achieved using intranasal medications.5., 7., 8. Midazolam is the most commonly studied medication for this indication, although data on fentanyl, ketamine, sufentanil, and combinations of these drugs are available.5 The data allow a few generalizations. First, intranasal medications are effective for mild to moderate sedation but not for deep sedation. Second, benzodiazepines and opiates produce varying levels of patient sedation, regardless of the route of

Seizure control: intranasal benzodiazepines

In situations where an intravenous line is not available, intranasally administered benzodiazepines offer a rapid, effective method to treat an acutely seizing patient. Fisgin et al9 found that intranasally administered midazolam was effective in 87% of patients with prolonged seizures, whereas rectally administered diazepam was only effective 60% of the time (P < 0.05). The authors concluded that intranasal midazolam is more effective, socially acceptable, and convenient than rectally

Nasopharyngeal procedures: nasal and oral 4% lidocaine

Nasogastric tube placement is a very painful procedure. Nevertheless, it is routinely performed with little or no analgesia.13 A number of prospective studies demonstrate that topical 4% lidocaine applied to both the nose and the throat results in dramatic reduction in pain compared with lidocaine jelly alone.13., 14. The addition of a topical vasoconstrictor also appears beneficial because of nasal mucosal shrinkage and the prevention of epistaxis. These data strongly suggest that topical

Epistaxis: nasal oxymetazoline and 4% lidocaine

Epistaxis is a common and messy problem, and its treatment can require substantial time and resources. Interestingly, otolaryngologists note that most epistaxis is easily controlled with intranasal oxymetazoline.16., 17. This method eliminates suction, cautery, and nasal packing, and the patient can continue topical oxymetazoline treatment at home. Triage nurses can start the treatment (in patients without significant cardiovascular disease), often resulting in bleeding cessation before the

Opiate overdose treatment: intranasal naloxone

Intravenous drug abusers requiring injectable naloxone place the emergency nurse at an especially high risk for bloodborne pathogen exposure.19 Because these patients rarely need an intravenous line for any reason beyond the administration of naloxone, it would be helpful to have a needleless method for administering the medication.20 Fortunately, naloxone is a small molecule that easily crosses the nasal mucosal membranes. Intranasal naloxone exhibits opiate antagonist effects almost as

Conclusion

Although the intranasal route is a rapid and convenient way to deliver medications in the emergency department, it will not replace the need for injections. However, awareness of its limitations combined with the correct equipment and medication concentrations will allow emergency nurses to bypass the need for intravenous lines in certain cases. This improves the safety of the work environment and eliminates the professional, personal, and family turmoil that may occur when a medical worker

First page preview

First page preview
Click to open first page preview

References (23)

  • R. Abrams et al.

    Safety and effectiveness of intranasal administration of sedative medications (ketamine, midazolam, or sufentanil) for urgent brief pediatric dental procedures

    Anesth Prog

    (1993)
  • Cited by (50)

    • Dexmedetomidine sedation vs. inhaled general anesthesia for pediatric MRI: A retrospective cohort study: Dexmedetomidine sedation vs. inhaled general anesthesia for MRI

      2022, Archives de Pediatrie
      Citation Excerpt :

      DEX can be administered by IV, intramuscular, subcutaneous, or IN routes making it a versatile agent in pediatrics when the IV route is challenging. The nasal mucosa is an easily accessible route that enables rapid absorption of drugs due to the large surface area, reaching a comparable bioavailability to that obtained with the IV route for some sedative agents [22]. Nevertheless, factors influencing the bioavailability of intranasally administered molecules are the concentration of the drug, the volume to be administered, the method of administration, and the condition of the nasal mucosa [22].

    • Intranasal route: The green corridor for Alzheimer's disease therapeutics

      2021, Journal of Drug Delivery Science and Technology
      Citation Excerpt :

      While performing in vivo experiments, rats or mice are given IN dose with the aid of a pipettor, breathing tube or instillator, and rhinyle catheter in anesthetized condition [124]. Whereas in practice, the patients are treated in actual condition with the compressed air nebulizers, squeezed bottle, meter dose pump sprays, atomizers for solution/suspension formulae [125,126]. Also, insufflators, dry powder inhalers, pressurized metered-dose inhalers are used for the powder dosage form [127].

    • The author responds: Assessing self-reported pain

      2017, American Journal of Emergency Medicine
    • A review of intranasal formulations for the treatment of seizure emergencies

      2016, Journal of Controlled Release
      Citation Excerpt :

      Additionally, drops may run out of the nose or drain faster than sprays into the nasopharynx, followed by swallowing. Gas pressurized sprays, i.e. atomizers, are even more efficient due to their greater surface area coverage in the nasal environment [111]. For atomizers, particle deposition efficiency is determined by nozzle characteristics such as cone angle and orifice size, which determine spray length, spray drop size, deposition area, etc.

    View all citing articles on Scopus
    View full text