| Aerosol Therapy | |
Aerosol generation and delivery to the lung is a complex and dynamic topic, with clinicians and researchers finding out more about its dynamics every day. The aerosol route of drug administration has become a preference for those treating pulmonary disease for a variety of reasons. The advantages of aerosol delivery of drugs include:
· Aerosol doses are smaller than those for systemic treatments.
· Onset of drug action is rapid.
· Drug delivery is directly targeted to the respiratory system.
· Systemic side effects are fewer and less severe than with oral or parenteral therapy
· Inhaled drug therapy is painless and relatively convenient.
As with nearly everything that has advantages, aerosol delivery of drugs also has its disadvantages, including:
· Special equipment is often needed for its administration.
· Patients generally must be capable of taking deep, coordinated breaths.
· There are a number of variables affecting the dose of aerosol drug delivered to the airways.
· Difficulties in dose estimation and dose reproducibility.
· Difficulty in coordinating hand action and breathing with metered dose inhalers.
· Lack of physician, nurse, and therapist knowledge of device use and administration protocols.
· Lack of technical information on aerosol producing devices.
· Systemic absorption also occurs through oropharyngeal deposition.
· The potential for tracheobronchial irritation, bronchospasm, contamination, and infection of the airway.
The common hazards of aerosol therapy are:
· Airway obstruction ‑ Dehydrated secretions in the patient’s airways may absorb water delivered via aerosol and swell up large enough to obstruct airways. To avoid this, watch the patient very closely and let him progress with therapy at a reasonable rate. You may want to have suction apparatus on hand.
· Bronchospasms ‑ It is common for aerosol particles to cause this condition (especially among asthmatics) and it is more prevalent when administering a cold aerosol as compared to a heated one. If a very large amount of coughing occurs, stop therapy and give the patient a rest. If this persists in farther therapy, stop treatment and notify the physician.
· Fluid overload ‑ This can occur when administering continuous aerosol therapy. It can happen quite frequently when treating infants or patients in congestive heart failure, renal failure or patients who are very old and immobile. In the infant, because of the smaller body size and possible underdeveloped fluid control mechanism, a quantity of water that an adult can easily handle will cause fluid overload. In a patient with congestive heart failure, any addition of fluid to the vascular system will put an increased strain on the heart. In a patient with renal failure who is probably already in fluid overload, it is easily seen that you will not want to increase the fluid volume. In older patients, the fluid control mechanisms may be impaired due to age.
The following are sample instructions for procedures to be followed related to aerosol applications:
The following procedure is provided for use when delivering medications by means of an aerosol generator:
A. Check Order. Verify the physician’s order as follows:
1. Compare the requisition with the physicians order to ensure that no discrepancies exist
2. Review the order to ensure that the following are prescribed:
· FIO2
· Medication to be used
· Frequency of therapy
· Duration of therapy
3. If any part of the order is unfamiliar, question its accuracy.
B. Review Chart. Use the following procedure to review the patient’s chart:
1. On the patient’s chart, identify all pertinent data in the following areas:
· History and physical
· Admitting diagnosis
· Progress notes
· Blood gas analysis
· Chest x‑rays
2. Based on the patient data, identify the following:
· Conditions that indicate the need for aerosol medication delivery
· Potential hazards of aerosol medication delivery for the patient
C. Maintain Asepsis. While performing the remainder of this procedure, you are expected to maintain aseptic conditions. This includes following universal precautions and washing your hands:
· Before obtaining equipment
· Following performance of step K. Conclude Procedure
· Anytime during the procedure that contamination is suspected
D. Obtain Equipment Collect the following equipment and supplies:
· Flowmeter or air compressor
· Miniature nebulizer
· Supply tubing
· Prescribed medication
· Stethoscope
E. Assemble Equipment. Prepare the equipment for use as follows:
1. Connect the supply tubing to the nebulizer.
2. Attach the other end of the supply tubing to the flowmeter.
3. Insert the prescribed medication into the nebulizer.
F. Test Equipment. Test the aerosol medication delivery equipment as follows:
1. Connect the flowmeter to the correct gas source.
2. Turn on the flowmeter.
3. If a fine mist is absent, tighten all connections and adjust the jets, if applicable.
4. If a fine mist is still absent:
a. Label the nebulizer as defective and replace it
b. Reassemble and retest the new equipment
G. Confirm Patient. Ensure that the procedure is performed with the correct patient as follows:
1. Match the information on the order with the following:
· Room number
· Name on the door or bed
· Name on the wristband
2. Greet the patient by name (in a questioning manner if unknown).
3. Resolve any discrepancies in the patient identification information by conferring with the nursing staff.
H. Inform Patient: Interact with the patient as follows:
1. Introduce yourself by name and department (if not already acquainted).
2. Tell the patient what procedure is to be performed.
3. Explain the procedure by describing:
· Why it is to be performed
· How it will be performed
· What the patient is expected to do
· What you will be doing
· How frequently it will be performed
I. Implement Procedure. Perform the following tasks:
1. Position the patient in an upright position (45 to 90° angle).
2. Administer the aerosol medication as follows:
a. Turn on the flow meter.
b. Attach the aerosol medication delivery device to the patient
c. Ensure that the delivery device fits comfortably.
3. Coach the patient to breathe in the following manner:
· Diaphragmatically
· Through the mouth
· Slowly and deeply
· Pause at end‑inspiration, maintaining an I:E ratio of at least 1:2
J. Monitor Patient. Determine the patient’s response to therapy as follows:
1. Determine the pulse rate. (Count for at least one minute.)
2. Determine the respiratory rate. (Count for at least one minute.)
3. Observe respiration to identify any abnormalities in the breathing pattern.
4. Auscultate the patient’s chest
5. Note any abnormalities in the patient’s appearance or behavior.
K. Conclude Procedure. Complete the following tasks:
1. Place the patient in a comfortable position.
2. Assure that the call bell and bedside table are within the patient’s reach.
3. Ask if the patient has any needs.
4. Answer any questions as effectively as possible.
5. Unplug and cover all equipment and move it away from the patient’s bed (or remove it from the room).
L. Record Results. Document the therapy as follows:
1. Record the following data on the patient’s chart:
· Aerosol medication administered
· Pulse rate
· Respiratory rate
· Volume, color, and consistency of sputum
· Abnormal patient characteristics
· Therapy‑related patient complaints
2. Sign the patient’s chart (first initial and full last name).
M. Report Observations. Report the following information:
1. Report any significant adverse changes in the patient’s condition to the nurse or physician whenever observed.
2. Following the procedure, inform the appropriate personnel of:
· Patient requests
· Patient complaints
· Unexpressed patient needs
3. Following the procedure, report to the nurse or physician:
· Any non‑critical adverse reactions to the therapy
· Other pertinent observations of the patients condition
The following procedure is provided for use when delivering medications by means of a metered dose inhaler:
A. Check Order. Verify the physician’s order as follows:
1. Compare the requisition with the physician’s order to ensure that no discrepancies exist.
2. Review the order to ensure that the following are prescribed:
· Medication to be used
· Frequency of therapy
· Duration of therapy
· Any special devices or chambers required
B. Review Chart. Use the following procedure to review the patient’s chart:
1. On the patient’s chart, identify all pertinent data in the following areas:
· History and physical
· Admitting diagnosis
· Progress notes
· Blood gas analysis
· Chest x‑rays
2. Based on the patient data, identify the following:
· Conditions that indicate the need for metered dose inhaler delivery
· Potential hazards of aerosol medication delivery for the patient
C. Maintain Asepsis. While performing the remainder of this procedure, you are expected to maintain aseptic. This includes the use of universal precautions and handwashing. Hands should be washed:
· Before obtaining equipment
· Following performance of Step J. Conclude Procedure
· Anytime during the procedure that contamination is suspected.
D. Obtain Equipment. Collect the following equipment and supplies:
· Metered Dose Inhaler (as prescribed)
· Any special devices or chambers (as applicable)
· Stethoscope
E. Assemble Equipment. Prepare the equipment for use as follows:
1. Shake the inhaler to mix the medications.
2. Remove the cap and attach the mouthpiece.
3. If a chamber is ordered, attach the device to the mouthpiece.
F. Confirm Patient. Ensure that the procedure is performed on the correct patient as follows:
1. Match the information on the order with the following:
· Room number
· Name on the door or bed
· Name on the wristband
2. Greet the patient by name (in a questioning manner if unknown).
3. Resolve any discrepancies in the patient identification information by conferring with the nursing staff.
G. Inform Patient. Interact with the patient as follows:
1. Introduce yourself by name and department (if not already acquainted).
2. Tell the patient what procedure is to be performed.
3. Explain the procedure by describing:
· Why it is to be performed
· How it will be performed
· What the patient is expected to do
· What you will be doing
· How frequently it will be performed
H. Implement Procedure. Perform the following tasks:
1. Position the patient in an upright position (45 to 90° angle).
2. Instruct the patient as follows:
a. Grasp the MDI medication chamber between the thumb and first two fingers with the thumb on the bottom of the chamber.
b. Hold the mouthpiece of the medication chamber (or additional chamber device if ordered) in front of the mouth with the lips around the mouthpiece but not closed on.
c. If the patient has difficulty holding the device without closing his lips, instruct him to rest the mouthpiece on the lower lip for balance.
d. Exhale completely. Begin to inhale deeply through the mouth and immediately compress the medication chamber between the thumb and fingers to release the medication.
e. Following complete inhalation, hold his/her breath for 5 to 10 seconds.
f. If an additional chamber was used, inhale from the device again, without compressing the medication chamber, to ensure complete aerosol delivery.
g. Repeat the process until the prescribed duration is accomplished.
I. Monitor Patient. Determine the patient’s response to the therapy as follows:
1. Determine the pulse rate. (Count for at least one minute).
2. Determine the respiratory rate. (Count for at least one minute).
3. Observe respiration to identify any abnormalities in the breathing pattern.
4. Auscultate the patient’s chest
5. Note any abnormalities in the patient’s appearance or behavior.
J. Conclude Procedure. Complete the following tasks:
1. Place the patient in a comfortable position.
2. Assure that the call bell and bedside table are within the patient’s reach.
3. Ask if the patient has any needs.
4. Answer any questions as effectively as possible.
K. Record Results. Record the following data on the laboratory data form and on the patient’s chart as required:
· Patient name Room number
· Aerosol medication delivered
· Pulse rate
· Respiratory rate
· Breath sounds
· Volume, color and consistence of sputum
· Any adverse patient reactions
· Therapy‑related patient complaints
L. Report Observations. Report the following information:
1. Report any significant adverse changes in the patient’s condition to the nurse or physician.
2. Following the procedure, inform the appropriate personnel of:
· Patient requests
· Patient complaints
· Unexpressed patient needs
3. Following the procedure, report to the nurse or physician:
· Any non-critical adverse reactions to the therapy
· Other pertinent observations of the patient’s condition
The following are several of the AARC’s Clinical Practice Guidelines relating to equipment used in respiratory care. These are presented to illustrate the type of information and detail contained in their CPGs.
AD 1.0 PROCEDURE:
Selection of a device for delivery of aerosol to the lower airways
AD 2.0 DESCRIPTION:
The selection of a device for administration of pharmacologically active aerosol to the lower airway. The device selected should produce particles with a mass median aerodynamic diameter (MMAD) of 2-5 microns.(1,2)
These devices include
Metered dose inhalers
(MDI)
MDIs with accessory device (e.g., spacer)
Dry powder inhalers (DPI)
Small volume nebulizers (SVN)
Large volume nebulizers (LVN)
Ultrasonic nebulizers (USN)
This guideline does not address bland aerosol administration and sputum induction.
AD 3.0 SETTING:
Aerosol therapy can be administered in a number of settings including hospital, clinic, extended care facility, and home.
AD 4.0 INDICATIONS:
The need to deliver—as an aerosol to the lower airways—a medication from one of the following drug classifications:
Beta adrenergic agents
Anticholinergic agents (antimuscarinics)
Anti-inflammatory agents (e.g., corticosteroids)
Mediator-modifying compounds (e.g., cromolyn sodium)
Mucokinetics
The selection of a device for delivery of aerosol for parenchymal deposition (e.g., antibiotics) will be addressed in another Guideline.
AD 5.0 CONTRAINDICATIONS:
5.1 No contraindications exist to the administration of aerosols by inhalation.
5.2 Contraindications related to the substances being delivered may exist. Consult the package insert for product-specific contraindications.
AD 6.0 HAZARDS/COMPLICATIONS:
6.1 Malfunction of device (3-5) and/or improper technique (6-12) may result in underdosing.
6.2 The potential exists for malfunction of device and/or improper technique (inappropriate patient use) to result in overdosing.
6.3 Complications of specific pharmacologic agent may occur.
6.4 Cardiotoxic effects of Freon have been reported as an idiosyncratic response that may be a problem with excessive use of MDI.(13-18)
6.5 Freon may affect the environment by its effect on the ozone layer.(19-21)
6.6 Repeated exposure to aerosols has been reported to produce asthmatic symptoms in some caregivers.(22)
AD 7.0 LIMITATIONS OF PROCEDURE OR DEVICE:
7.1 Only a small percent of output deposits in the airway (< or = 10%).23-27
7.2 Efficacy of the device is technique dependent (e.g., coordination, breathing pattern, inspiratory hold).(6-9,28-32) The reader is referred to Kacmarek RM, Hess D. The interface between patient and aerosol generator. Respir Care 1991;36:952-976 for detailed descriptions of optimal technique.
7.3 Efficacy of the device is design dependent (ie, output and particle size).(4,5,33)
7.4 Reduced deposition of aerosol to the lower airways is associated with the following and may require consideration of increased dose:
7.4.1 mechanical ventilation;(26,27,34-36)
7.4.2 artificial airways;(34-39)
7.4.3 airway caliber (e.g., infants and children);(22,37-39)
7.4.4 severity of obstruction.(40-42)
7.5 Patient compliance(12)
7.6 Limitations of specific devices
7.6.1 Metered Dose Inhaler:
7.6.1.1 Environmental concerns(CFC)(20,21)
7.6.1.2 Inadequate technique(6-8,28-32,43)
7.6.1.3 Inadequate instruction(9-12)
7.6.2 MDI accessory device (spacer or holding chamber):
7.6.2.1 Adds to cost over MDI alone
7.6.2.2 More bulky than MDI alone
7.6.3 Dry powder inhaler:
7.6.3.1 At the present time, patients must load each dose for most medications.
7.6.3.2 Reduced inspiratory flow (< 60 L/min) can lead to reduced deposition.(44-46)
7.6.3.3 Irritation to airway (33)
7.6.3.4 Humidity may cause clumping of particles.
7.6.4 Small Volume Nebulizer:
7.6.4.1 Time- and labor-intensive
7.6.4.2 Less portable
7.6.4.3 Requires compressed-gas source or electricity
7.6.4.4 Vulnerable to contamination (47-50)
7.6.4.5 Lack of convenience may affect patient compliance
7.6.5 Large Volume Nebulizer:
7.6.5.1 Limited to acute and critical care setting
7.6.5.2 Requires close monitoring
7.6.5.3 Time- and cost-intensive
7.6.5.4 Vulnerable to contamination (46-49)
7.6.5.5 Reconcentration of solution may occur over long period of time due to evaporation by dry gas.
7.6.6 Ultrasonic Nebulizer:
7.6.6.1 Cost of device
7.6.6.2 Mechanical reliability
7.6.6.3 Requires electrical power source
7.6.6.4 Vulnerable to contamination
AD 8.0 ASSESSMENT OF NEED:
8.1 Based on proven therapeutic efficacy, (25,51-60) variety of available medications, and cost-effectiveness (51,61-64) the MDI with accessory device should be the first method to consider for administration of aerosol to the airway.
8.2 Lack of availability of prescribed drug in MDI, dry powder, or solution form.
8.3 Inability of the patient to use device properly with coaching and instruction should lead to consideration of other devices.
8.4 Patient preference for a given device that meets therapeutic objectives should be honored.
8.5 When there is need for large doses, MDI, SVN, or LVN may be used. Clear superiority of any one method has not been established. Convenience and patient tolerance of procedure should be considered.
8.6 When spontaneous ventilation is inadequate (e.g., as in kyphoscoliosis or neuromuscular disorders, exacerbation of severe bronchospasm with impending respiratory failure that does not respond to other forms of therapy), delivery by a positive pressure breathing device (IPPB) should be considered.(65-67)
AD 9.0 ASSESSMENT OF OUTCOME:
9.1 Proper technique applying device
9.2 Patient response to or compliance with procedure
9.3 Objectively measured improvement (e.g., increased FEV1 or peak flow)
AD 10.0 RESOURCES:
10.1 Equipment:
10.1.1 MDI-canister with actuator supplied by manufacturer; MDI accessory device that properly fits MDI mouthpiece or mask; adapters for specific circumstances (e.g., tracheostomy)
10.1.2 Small volume nebulizer—gas source, tubing, flowmeter, and mouthpiece or mask
10.1.3 Large volume nebulizer—gas source, flowmeter, connecting tubing, and mouthpiece or mask
10.1.4 Mechanical ventilator—SVN or MDI, adapter in inspiratory line of circuit
10.1.5 IPPB machine (ie, pressure-limited ventilator)-nebulizer, gas source, connecting tubing, and mouthpiece or mask
10.1.6 Manual resuscitator—for ‘bagging in’ aerosol from MDI or SVN
10.2 Personnel:
10.2.1 Knowledge and skills at several levels are required to fully utilize and apply these devices.
10.2.1.1 Level II personnel provide initial assessments and care of the unstable patient:
10.2.1.1.1 utilizing proper technique for administration of MDI, accessory device, dry powder inhaler, SVN, LVN, USN; and SVN via IPPB;
10.2.1.1.2 practicing proper use, maintenance, and cleaning of equipment;
10.2.1.1.3 encouraging effective breathing patterns and coughing techniques;
10.2.1.1.4 modifying technique in response to adverse reactions;
10.2.1.1.5 modifying dosages and/or frequency as prescribed in response to severity of symptoms;
10.2.1.1.6 assessing patient condition and response to therapy;
10.2.1.1.7 performing auscultation and inspection and taking vital signs;
10.2.1.1.8 performing peak expiratory flowrate, spirometry, or ventilatory mechanics;
10.2.1.1.9 recognizing and responding to therapeutic and adverse responses and complications of medication and/or procedure;
10.2.1.1.10 understanding and complying with Universal Precautions.
10.2.1.2 The patient, family, or home caregiver; Level-I hospital personnel provide routine care of the patient:
10.2.1.2.1 preparing, measuring, and mixing medication;
10.2.1.2.2 demonstrating proper technique for administration of medication;
10.2.1.2.3 using equipment properly;
10.2.1.2.4 cleaning equipment;
10.2.1.2.5 encouraging effective breathing patterns and coughing techniques;
10.2.1.2.6 modifying technique in response to adverse reactions as instructed, with appropriate communication with physician or Level-II care provider;
10.2.1.2.7 modifying dosages and/or frequency as prescribed, with appropriate communication with physician, in response to severity of symptoms;
10.2.1.2.8 using the peak flowmeter properly and documenting results.
AD 11.0 MONITORING:
11.1 Performance of the device
11.2 Technique of device application
11.3 Assessment of patient response including changes in vital signs
AD 12.0 FREQUENCY:
12.1 Initiation of therapy after careful assessment of need (as outlined
above)
12.2 The change from one type of device to another is based on a change
in patient’s condition or ability to use the specific device.
AD 13.0 INFECTION CONTROL:
13.1 Universal Precautions must be exercised for body substance isolation.(67)
13.2 SVN and LVN are for single patient use or should be subjected to high-level disinfection between patients.
13.3 Published data establishing a safe use-period for SVN and LVN are lacking; however they probably should be changed or subjected to high-level disinfection at approximately 24-hour intervals.
13.4 Medications:
13.4.1 Medications should be handled aseptically.
13.4.2 Tap water should not be used as the diluent.(69)
13.4.3 Medications from multidose sources in acute care facilities must be handled aseptically and discarded after 24 hours, unless manufacturer’s recommendations specifically state that medications may be stored longer than 24 hours.
13.5 MDI accessory devices are for single patient use only. Cleaning of accessory devices is based on aesthetic criteria.
13.6 There are no documented concerns with contamination of medication in MDI canisters.
Aerosol Guidelines Committee:
Jon Nilsestuen PhD RRT, Chairman, Houston TX
Jim Fink MBA RRT, San Francisco CA
Theodore Witek Jr DrPH RPFT RRT, Ridgefield CT
James Volpe III MEd RRT, San Diego CA
BAA 1.0 PROCEDURE:
Bland aerosol
administration
BAA 2.0 DESCRIPTION/DEFINITION:
For purposes of this
guideline, bland aerosol administration includes the delivery of sterile water
or hypotonic, isotonic, or hypertonic saline in aerosol form .1 Bland aerosol
administration may or may not be accompanied by oxygen administration.
2.1 The use of cool, bland aerosol therapy is
primarily indicated for upper airway administration; 1,2 therefore,
a mass median aerodynamic diameter (MMAD) ≥ 5 micron is desirable.
2.2 The use of hypo- and hypertonic saline is
primarily indicated for inducing sputum specimens; therefore, a MMAD of 1-5
microns is desirable.
2.3 The use of
heated bland aerosol is indicated primarily for minimizing humidity deficit
when the upper airway has been bypassed;3 therefore, a MMAD of 2-10
microns is desirable.
BAA 3.0 SETTINGS:
Bland aerosol therapy can
be administered in settings that include hospital, clinic, extended care
facility, and home.
BAA 4.0 INDICATIONS:
4.1 The presence of upper airway edema—cool bland aerosol1,2
4.1.1 Laryngotracheobronchitis (LTB)1,2
4.1.2 Subglottic
edema1,2
4.1.3
Post-extubation edema1,2
4.1.4 Postoperative
management of the upper airway
4.2 The presence of a bypassed upper airway3
4.3 The need for
sputum specimens or mobilization of secretions3,4
BAA 5.0 CONTRAINDICATIONS:
5.1 Bronchoconstriction1,3,5,6
5.2 History of
airway hyperresponsiveness1,2,5,6
BAA 6.0 HAZARDS/COMPLICATIONS:
6.1 Wheezing or bronchospasm1,3,5,6
6.2
Bronchoconstriction when artificial airway is employed7-11
6.3 Infection12
6.4 Overhydration12
6.5 Patient
discomfort
6.6 Caregiver
exposure to droplet nuclei of Mycobacterium
tuberculosis or other airborne contagious microorganism produced as
a consequence of coughing, particularly during sputum induction
6.7 Edema of the
airway wall13
6.8 Edema associated
with decreased compliance and gas exchange and with increased airway resistance
6.9 Sputum induction
by hypertonic saline inhalation can cause bronchoconstriction with patients who
have COPD,1 4 asthma, cystic fibrosis, or other pulmonary diseases.15
BAA 7.0 LIMITATIONS OF METHOD:
7.1 The efficacy of intermittent or continuous
use of bland aerosol as a means of reducing mucus has not been established.1
- 3 Bland aerosol is not a substitute for systemic hydration.
7.2 The physical
properties of mucus are only minimally affected by the addition of water
aerosol.16
7.3 Bland aerosol
for humidification when the upper airway has been bypassed is not as efficient
or effective as are heated water humidifiers or adequately designed heat
moisture exchangers (HME) because of the
7.3.1 Difficulties in maintaining temperature
at patient airway
7.3.2 Possible irritation
to the airway7-11
7.3.3 Infection risk12
BAA 8.0 ASSESSMENT OF NEED:
8.1 The presence of one or more of the following may be an indication for administration of sterile water or isotonic or hypotonic saline aerosol:
8.1.1 Stridor
8.1.2 Brassy, croup-like
cough
8.1.3 Hoarseness
following extubation
8.1.4 Diagnosis of
LTB or croup
8.1.5 Clinical
history suggesting upper airway irritation and increased work of breathing (eg,
smoke inhalation)
8.1.6 Patient
discomfort associated with airway instrumentation or insult
8.1.7 Bypassed upper
airway
8.2 The presence of the need for sputum induction (eg, for diagnosis of Pneumocystis carinii pneumonia,17-19 tuberculosis) is an indication for administration of hypertonic saline aerosol.
BAA 9.0 ASSESSMENT OF OUTCOME:
9.1 With administration of sterile water or hypotonic or isotonic saline, the desired outcome is the presence of one or more of the following:
9.1.1 Decreased work of breathing
9.1.2 Improved vital
signs
9.1.3 Decreased
stridor
9.1.4 Decreased
dyspnea
9.1.5 Improved
arterial blood gas values
9.1.6 Improved
oxygen saturation as indicated by pulse oximetry (SpO2)
9.2 With administration of hypertonic saline, the desired outcome is a sputum sample adequate for analysis.
BAA 10.0 RESOURCES:
10.1 Equipment—Depending upon the specific application, components may include:
10.1.1 Aerosol generator
10.1.1.1 Large-volume nebulizer
10.1.1.2 Ultrasonic
nebulizer
10.1.1.3
Small-volume nebulizer
10.1.2 Heater or cooling device
10.1.3 Patient
application device
10.1.3.1 Mist tent
10.1.3.2 Hood
10.1.3.3 Mouthpiece
10.1.3.4 Mask
10.1.3.5 T-piece
10.1.3.6 Face tent
10.1.3.7
Tracheostomy collar
10.1.4 Corrugated aerosol tubing and water trap
10.1.5 Tissues and
emesis basin or container for collecting or disposing of expectorated sputum
10.1.6 Gloves,
goggles, gown, and mask
10.1.7 Suction
device and catheters
10.1.8 Oxygen
analyzer
10.1.9 Device for
filtering exhaled gas during sputum induction, with scavenger or filter system
10.1.10 Thermometer
10.2 Resources—Personnel
10.2.1 Level I caregiver may be the provider of service after Level II personnel have established need for a specific device by patient assessment and the first administration has been completed. Level I personnel must demonstrate:
10.2.1.1 Proper preparation, measurement, and
mixing of solution
10.2.1.2 Proper
technique for administration of solution to be aerosolized
10.2.1.3 Proper use
of equipment
10.2.1.4 Effective
cleaning of equipment
10.2.1.5 Appropriate
disposal of wastes
10.2.1.6 Ability to
encourage effective
breathing patterns and coughing techniques
10.2.1.7 Ability to
modify techniques in response to adverse reactions as instructed and to
appropriately communicate with physician, detailing the severity of symptoms
10.2.1.8 Compliance
with Standard Precautions and proper infection control procedures
10.2.2 Level II personnel supervise Level I personnel, are responsible for initial assessments and care of the unstable patient, and must demonstrate knowledge and skill related to:
10.2.2.1 Indications and limitations for aerosol
devices and associated equipment
10.2.2.2 Proper use,
maintenance, and cleaning of equipment, including filter and scavenging systems
10.2.2.3 Risks
inherent to the aerosolized solution and specific devices
10.2.2.4 Procedures
for safely disposing of hazardous wastes
10.2.2.5 Breathing
patterns and coughing techniques
10.2.2.6
Modification of technique in response to adverse reactions
10.2.2.7
Modification of flowrates and temperature as prescribed, in response to
severity of symptoms
10.2.2.8 Assessment
of patient condition and response to therapy
10.2.2.9
Auscultation, inspection, and monitoring of vital signs
10.2.2.10
Determination of peak expiratory flowrate, spirometry, and ventilatory
mechanics
10.2.2.11
Recognition and response to adverse reactions and complications of procedure
10.2.2.12
Understanding of and compliance with Standard Precautions
10.2.2.13 Proper
disposition of medical waste
BAA 11.0 MONITORING:
The extent of patient monitoring should be determined on the basis of the
stability and severity of the patient’s condition.
11.1 Patient subjective response—pain,
discomfort, dyspnea, restlessness
11.2 Heart rate and
rhythm, blood pressure
11.3 Respiratory
rate, pattern, mechanics, accessory muscle use
11.4 Sputum production: quantity, color,
consistency
11.5 Skin color
11.6 Breath sounds
11.7 Pulse oximetry
11.8 Spirometry
equipment (if concern of adverse reaction)
BAA 12.0 FREQUENCY:
12.1 Critical care or emergency room settings that require continuous administration of bland aerosol necessitate close monitoring.
12.1.1 Short duration: 4-8 hours following
extubation
12.1.2 Subglottic
edema: until clinical evidence of edema has subsided
12.1.3 Long
duration: artificial airways
12.1.4 Re-evaluation
every 8 hours or with change in clinical condition
12.2 Acute care patients should be evaluated
for response to therapy of continuous administration of bland cool aerosol for
LTB and reevaluated at least every 48-72 hours or with change in clinical
response.
12.3 Home care
patients should be re-evaluated periodically for response to therapy or with
change in status.
12.4 Sputum
induction should be performed as often as necessary to yield appropriate
specimen for desired examination (eg, each morning for 3 days for acid-fast
bacillus).
BAA 13.0 INFECTION CONTROL:
13.1 Standard Precautions for body fluid
isolation are to be implemented.20
13.2 Centers for
Disease Control and Prevention recommendations for control of exposure to
tuberculosis and droplet nuclei are to be implemented when patient is known or
suspected to be immunosuppressed, is known to have tuberculosis, or has other
risk factors for the disease. 21
13.2.1 To reduce aerosol contamination of room air
13.2.1.1 Enclose and contain aerosol
administration.
13.2.1.2 Filter
aerosols that bypass or are exhaled by patient.
13.2.1.3 When
aerosol release to the atmosphere cannot be routed through a filter:
13.2.1.3.1 Use filtered scavenger systems to remove
aerosols that cannot be contained.
13.2.1.3.2 Provide
local exhaust ventilation to remove aerosols that are released into room air.
13.2.1.3.3 Provide
frequent air exchange to dilute concentration of aerosol in room.
13.2.1.3.4 Allow
exchange of gas in the room to eliminate 99% of aerosol before next patient
enters or receives treatment in that area.
13.2.1.3.5 Provide
booths or stalls for sputum induction in areas in which multiple patients are
treated. Booths or stalls should be designed to provide adequate airflow to
draw aerosol and droplet nuclei from the patient and into an appropriate
filtration system with exhaust directed to an appropriate outside vent. Booths
should be adequately cleaned between patients.
13.2.2 Filters, nebulizers, and other
contaminated disposable components of the aerosol delivery system should be
treated as hazardous waste.
13.2.3 Personal
protection devices should be used to reduce exposure when engineering
alternatives are not adequate or in place.21
13.2.3.1 Use properly fitted respirator with
adequate filtration when flow exhaust cannot control removal of aerosols.
13.2.3.2 Goggles,
gloves, masks, and gowns should be used to serve as splatter shields and to
reduce exposure to body substances.
13.2.4 Personnel should safely dispose of
hazardous wastes.
13.2.5 Personnel who
are at high risk for adverse effects from exposure should be given alternative
assignments.
13.3 Nebulizers should not be reused between
patients without disinfection.
13.4 Nebulizers
should be sterilized, changed, or cleaned according to institutional infection
control policy or at conclusion of a procedure that is not to be repeated.22,23
13.5 Solutions
should be handled aseptically.
13.6 Solutions from
multidose sources must be handled aseptically and discarded after 24 hours.
Revised by Thomas J Kallstrom RRT, FA A R C ,
Fairview Hospital, Cleveland, Ohio, and
approved
by the 2003 CPG Steering Committee
Original Publication: Respir Care
1993;38(11):1196-1200.
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