Nurses in Allergy Edition 1

Standard Operating Procedure

Nasal Douching
Using a nasal douche as a solo or adjunctive treatment is recognised as beneficial in reducing
nasal symptoms where infection and/ or nasal allergy have been identified as a cause. Nasal
douching or nasal irrigation as it is sometime called is a safe and simple system of washing out the
nose and can be performed in several different ways.

Sinonasal disease can lead to damage of the mucociliary transport system inside the nose.
Research has shown that mucus contains inflammatory mediators and when its transportation
through the nose becomes slow due to poor ciliary function, inflammation can increase. Nasal
irrigation is considered beneficial in removing thickened mucus and therefore reducing
inflammation (9, 13). For many years Ear Nose and Throat surgeons have used nasal douching as
a post operative cleansing treatment to aid in the healing process after surgery. Nasal douching
may be particularly helpful for rhinosinusitis

Douching the nose is also recommended before applying a corticosteroid nasal treatment and
therefore particularly useful for patients being treated for rhinitis. Douching will remove lingering
mucus cleansing the mucous membranes to aid in maximum surface exposure on which to apply
medicated treatments. It has been shown that nasal douching before the use of a steroid nasal
spray will enhance efficacy and generally improve symptomatic control (3).

The benefits of using an isotonic solution have been reported and research has shown no changes
to the mucous membranes of the lining of the nose when used regularly. The solution can be an
isotonic balanced salt solution or a hypotonic solution containing only salt to aid in osmotic mucus
drainage from the sinuses.

Nasal douching is not a medicated solution. An isotonic solution can be safely used by all age
groups, adults and children (5, 6), to support daily nasal hygiene. It can be used as a base line
preparation treatment or alone in mild symptomatic disease and is an alternative treatment when a
person is unwilling or unable to use a medicated nasal spray containing steroid. Caution should be
taken with regards to sodium overload ensuring patients do not swallow any solution (e.g. in
patients with hypertension or renal disease).

A solution can be mixed-up at home, or commercial products are available to the public from the
pharmacy or via the internet.

 There are several proprietary products on the market which aid in the application of a nasal
douching solution. Please see table 1 below for examples.
 Using a proprietary product for children under twelve years may make nasal douching more
acceptable and safer where there is uncertainty about mixing up a homemade solution.
 The ready mixed sprays available are very convenient for all users but particularly make nasal
douching acceptable for younger children.
 Some companies provide the mixed dry ingredients in sachets to add to cooled boiled water to
make a solution.
 Using commercial products will make the process of nasal douching easier but at considerable
cost for the user.
 Using commercial products can support compliance in performing douching and encourage its
regular use.

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 Nurses in Allergy Edition 1
Standard Operating Procedure

How to perform nasal douching

 Wash hands before performing the procedure
 Douching can be performed in the morning and or evening, or more frequently if
severe infection is active and advised by a clinician.

A balanced isotonic solution can be made at very little cost using home ingredients. Its application
requires no specialised equipment and the fluid is sniffed into the nose from a mug or cupped hands.

Ingredients for isotonic douching solution

240 mls previously boiled and cooled water
equal parts: 1/4 teaspoon salt
1/4 teaspoon bicarbonate of soda

ACTION RATIONALE
Use clean equipment Ensure there are no visible Ensuring equipment is clean
A spoon and mug in which to residual crystals from and free from food or crystal
previous douching use particles prevents risk of
mix ingredients together further nasal irritation

Measure out dry ingredients No specific type of salt is The salt and bicarbonate
required but it must be together create a balanced
clean and free from other isotonic solution
1/4 teaspoon salt food contaminates

1/4 teaspoon bicarbonate of Bicarbonate of soda often This balanced mix should
soda referred to as baking soda prevent the solution from
is sold from the cooking stinging inside the nose.
section of most general Equivalent to our own tears.
food stores

Mix dry ingredients with Ensure the dry ingredients The water must be boiled
have dissolved before before use to allow for
boiled water that has proceeding and ensure the sterilization and to remove
cooled down solution is room harmful elements from the tap
temperature water

Do not keep solution ready Using the solution at room

mixed for longer than 24 temperature should be
hours acceptable to the nose and will
Do not store in fridge not cause burning from being
Do not heat solution in too hot, or nasal sensitivity
microwave from being too cold
Lean over a sink
Bring mug of solution to Do not sniff up large A small amount of douche
nose amounts of liquid solution should be sniffed into
the nasal cavity and allowed to
Do not swallow liquid run back out of the nose once
Sniff a small amount of the sniffing has stopped
fluid into the nose for
approximately two to three Sniffing too much solution
may cause it to be swallowed
seconds or cause choking

Alternatively
Use cupped hands pouring
solution into hand and sniff

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 Nurses in Allergy Edition 1
Standard Operating Procedure
from hand

Take nose away from the

mug As a wash the liquid should be
sniffed into the nose and
Allow the liquid to run back allowed to run back out
out of nose into the sink

To cleanse both sides of the This ensures that the solution

has entered both sides of the
nasal cavity it may be nose
necessary to block each nostril
alternatively as you sniff

Repeat this action several The nose may water The natural cleansing
naturally after nasal processes of the nose will be
times as tolerated ideally until stimulated by douching
douching and this should
all the solution has been used be expected

After nasal douching blow your Always blow the nose If nasal treatments are applied
gently so as not to over whilst the nose is watering the
nose and let it rest for 10-20 treatment spray will be
stimulate or cause damage
minutes before applying any inside the nose washed out of the nose
treatment spray reducing its effectiveness.

Alternative devices and ready mixed preparations to aid douching

1. A twenty ml syringe (without needle) may be used to squirt the solution into the
nose rather than sniffing it up.

2. Using a device like a small jug or tea pot to pour the solution into one nostril
allowing gravity to let it run out through the other nostril has been successfully used
by many of Eastern origin. The mouth is kept open to breathe through whilst
performing the process. Jala-neti, means to cleanse the nose with water, which is
an old yogic technique from India.
Neti pots are available on the commercial market.(6)

3. Using a squeezy bottle is a high-volume, low-pressure system. The solution is

squirted into one nostril allowing it to run out of the other nostril and has been found
to be a very effective delivery device. The mouth is kept open to breathes through
whilst performing the process.
SinuRinse bottles are available on the commercial market.

4. A douching spray is a ready mixed solution in a canister needing no preparation.

This makes it a very convenient device readily available and easy to apply and
incorporate into daily life. The convenience will encourage compliance toward
regular use of nasal douching and likely other treatment regimes. This can be
especially useful when staying away from home to support continued treatment use.
Sterimar Spray and Nasal Mist are available on the commercial market.

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 Nurses in Allergy Edition 1
Standard Operating Procedure

Nasal Douching Aids for purchase: Table1

Manufacturer Name of product Where can be purchased

Neilmed products SinuRinse Bottle From a UK pharmacy or

adult and child sizes online
Except for the spray these
products come with sachets Neti pot
of mixed powder to add to
cooled previously boiled Sinugator pulsing irrigator
water to make up a solution. Nasal mist
www.Neilmed.com

Sterimar Sterimar seawater spray From a UK pharmacy or

online
www.sterimarnasal.co.uk Isotonic or hypertonic

Emcur Emcur irrigation system From a UK pharmacy or

online
www.emcur.co.uk

Yogamatters Neti pot - plastic, White

Acu-Life Neti-Rinse Nasal Irrigator Online

Toddletime Ltd Emmay Care Health Nasal Online

Aspirator

References:
1. ARIA, Allergic Rhinitis and its Impact on Asthma (2007). Full Text documents and
resources: http://www.whiar.org

2. Brown CL, Graham SM (2004). "Nasal irrigations: good or bad?". Curr Opin Otolaryngol
Head Neck Surg 12 February (1): 9–13

3. Scadding GK, Durham SR, Mirakian R, Jones NS, Drake-Lee AB, Ryan D, Dixon TA,
Huber PAJ and Nasser SM. BSACI guidelines for the management of allergic and non-
allergic rhinitis 2008 http://www.bsaci.org/ guidelines Clin.Exp.Allergy Vol 38, 19-42

4. Dunn JD, Dion GR, McMains KC 2013. Efficacy of nasal irrigations and nebulizations for
nasal symptom relief. Curr Opin Otolaryngol Head Neck Surg. Jun;21(3):248-51.

5. Garavello W et al 2003 Hypersaline nasal irrigation in children with symptomatic seasonal

allergic rhinitis: A randomised study. Pediatric Allergy and Immunology. 14: 140-143

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 Nurses in Allergy Edition 1
Standard Operating Procedure

6. James T C Li, M.D., Ph.D. What is a Neti Pot? and why would you use one? Mayo Clinic
www.mayoclinic.org accessed February 2014

7. Khianey R, Oppenheimer J 2012 Is nasal saline irrigation all it is cracked up to be?

Ann Allergy Asthma Immunol Jul;109(1):20-8.

8. Middleton PG Geddes DM Alton EW 1993 Effect of amiloride and saline on nasal

mucociliary clearance and potential difference in cystic fibrosis and normal subjects Thorax
48: 812-816

9. Olson, D. E. L.; Rasgon, B. M.; Hilsinger, R. L. (2002). "Radiographic Comparison of Three

Methods for Nasal Saline Irrigation". The Laryngoscope 112 (8): 1394–1398.

10. Pynnonen, M. A.; Mukerji, S. S.; Kim, H. M.; Adams, M. E.; Terrell, J. E. (2007). "Nasal
Saline for Chronic Sinonasal Symptoms: A Randomized Controlled Trial". Archives of
Otolaryngology - Head and Neck Surgery 133 (11): 1115–1120.

11. Scadding GK 1999 Nasal douching as a valuable adjunct in the management of chronic
rhinosinusitis. Rhinology 37(1):29-32.

12. Tomooka LT, Murphy C, Davidson TM (2000). "Clinical study and literature review of nasal
irrigation". Laryngoscope 110 (7): 1189–93.

13. Wingrave W 1902 The nature of discharges and douches. Lancet May: 1373-1375

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