Continuous Bronchodilator Nebulization Protocols.

4/3/2014
Continuous Bronchodilator
Nebulization
Protocols.
Douglas E. Masini, EdD, RRT-NPS, FCCP, FAARC
Savannah, GA
The views expressed in this presentation are Doug
Masini’s,, and do not represent the policy or opinions
Masini’s
of Armstrong Atlantic State University, Mercer
University or Quillen College of Medicine
Medicine.. Dr
Dr.. Masini
states no conflict of interest in this presentation
presentation..
The ‘History and Physical’ of continuous nebulization
- Open Heart intra-op and post-op ‘Bagged in’ nebulizers,
Options for IPPB q 30 min., then q 1hr., q 2 hr., etc.
- Child with asthma in 1984, ordered “CAM tent at
30%…continuous nebulization of ‘straight’ 1 mg/ml aliquots
of terbutaline for 8 hrs. and call house officer.”
- Literature Review for presentation to Medical Staff in 1986
found hundreds of peer-reviewed articles; many performed
by vendors and entities with direct benefit from outcomes.
- Worked in 1988 with Medical Staff to establish safe
practices committee and evaluate outcomes.
- 1990, continued to collect new evidence and application as
a rescue technique.
- Meds include multi-dose 0.5% sol (5 mg/ml), unit-dose
0.08%, terbutaline 1 mg/ml, racemic epinephrine 2.25%,
epinephrine, levalbuterol (1.25 mg).
1
4/3/2014
Continuous
Bronchodilator
Nebulization
Protocols.
Peters findings:
- Intermittent treatments administered as 2.5 mg of
albuterol at 30-min intervals, while continuous
treatment consisted of 10 mg of albuterol over 2 hr.
- No overall differences in peak expiratory flow rate
(PEFR) or frequency of hospital admission.
- However, for patients with baseline PEFR 200
L/min, continuous albuterol resulted in better PEFR,
lower rate of hospitalization, and greater decrease in
heart rate.
- May be superior for those patients with the most
severe airflow limitation.
http://journal.publications.chestnet.org/data/Journals/CHEST/22052/zcb00107000286.pdf
2
4/3/2014
http://www.ncbi.nlm.nih.gov/pubmed/9647274
Courtesy Mike McPeck, RRT
3
4/3/2014
Raabe etal used a HEART nebulizer.
-The nebulizer was operated from a single compressed air or
oxygen source and found to provide from 10 to 15 L/min of
aerosol with 38 to 50 microL of aerosolized medicine per liter
of air (or oxygen) and utilize from 30 to 56 mL/hour of
medicinal liquid.
- The mass median aerodynamic diameter (mmad) of the
aerosol droplets was found to be about 2.0 μm (sigma(g) =
2.7). Delivery efficiency to the patient mask was about 90%.
- The aerosolized medicine delivered to the patient can be
increased by adjusting the flow rate of the gas source or
changing the solution concentration of medicine.
- Typically, several milligrams of drug can be delivered to the
patient as inhaled aerosol per hour of treatment; about onequarter can be expected to be deposited in the lungs.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/9647274
©2010 by American Academy of Pediatrics
4
4/3/2014
Rudnitsky etal findings: Mean +/- SD heart rate in
the subgroup analysis was 102 +/- 21 at baseline
for the continuous group and 109 +/- 22 at
baseline in the intermittent group. At 120 mins.,
heart rate was 90 +/- 18 in the continuous group
and 104 +/- 16 in intermittent group (P = .002).
Conclusion: Continuous nebulization offers no
benefit over intermittent therapy in patients with
an initial PEFR of more than 200 L/min. In PEFRs of
200 or less, continuous nebulization may decrease
admission rate and improve PEFRs when
compared with standard therapy.
Available at : http://www.ncbi.nlm.nih.gov/pubmed/8239105?dopt=Abstract
http://journal.publications.chestnet.org/article.aspx?articleid=1080781
Rodrigo & Rodrigo findings: Six studies including 393 adults with
acute asthma were selected.
- Four studies recorded FEV1 as percent predicted, three recorded
absolute FEV1, and two recorded both percent predicted and absolute
PEF. No significant differences were demonstrated between the two
delivery methods in terms of pulmonary function measures obtained
after 1 h of treatment.
- At the end of treatment, there was a significantly greater decrease
in pulse rate when the continuous nebulizer was used - Additionally,
the analysis showed a significant decrease of serum potassium
concentration with the use of intermittent nebulization .
- At the end of the study period, no significant differences were
identified between patients treated with continuous or intermittent
nebulization with respect to hospital admission
Conclusions: Overall, this review supports the equivalence of
continuous and intermittent albuterol nebulization in the treatment
of acute adult asthma.
Available at http://journal.publications.chestnet.org/article.aspx?articleid=1080781
5
4/3/2014
http://journal.publications.chestnet.org/article.aspx?articleid=1080781
1. “ If you load …the HEART, the 20 mg/hr dosing scenario
is actually about 3.5 mg/hour, about the same as 6 backto-back treatments with a standard SVN and 0.083%
albuterol in an hour. Hence, the labor saving for the
same amount of drug delivery.”
2. “Different devices (HEART, Hope, Misty Finity, etc.),
actually deliver different drug masses to the patient so
that all continuous nebulization devices are not equal in
drug delivery.”
3. According to the studies I did, the HEART delivers the
greatest amount in the Large Volume category. (I
haven't studied the small volume continuous devices).
- Mike McPeck on continuous nebulization.
6
4/3/2014
Results. The mean change in PI score from baseline
to 240 minutes or ED discharge was 6.67 for the
heliox group compared with 3.33 for the oxygen
group. Eleven (73%) patients in the heliox group
were discharged from the hospital in <12 hours
compared with 5 (33%) patients in the conventional
group.
Conclusion. Continuously nebulized albuterol
delivered by heliox was associated with a greater
degree of clinical improvement compared with that
delivered by oxygen among children with moderate
to severe asthma exacerbations.
http://pediatrics.aappublications.org/content/116/5/1127.full
7
4/3/2014
Research Articles
Considered During
This Work
Thank You to
Mike McPeck, BS, RRT, FAARC for his
assistance and input.
8