I. Subject: Continuous Aerosolization of Bronchodilators II. Indications: A. Acute airflow obstruction in which treatment with an aerosolized bronchodilator is desired for an extended period of time, i.e. status asthmaticus. III. Contraindications: A. Known hypersensitivity to delivered medication. B. Infant with known systemic fluid overload. C. Relative contraindication in patients with known cardiac dysfunction and/or hypertension. IV. Rationale: Status asthmaticus may be defined as an exacerbation of asthma that does not respond to usual therapeutic efforts. Standard therapy may include oxygen, theophylline, corticosteroids, subcutaneous epinephrine and intermittently nebulized Beta-agonist agents such as albuterol. Literature has been published showing gratifying results in the patient with acute airflow obstruction when treated with aerosol bronchodilator agents at intervals much more frequent than traditionally recommended therapy. Even more recently, published literature has suggested that doses of continuously nebulized bronchodilator medication in the pediatric population may be a preferred treatment for status asthmaticus. Some studies suggest that continuous nebulization may produce superior bronchodilation than intermittent therapy. One theory suggests that improved penetration and therefore improved efficacy of subsequent doses of medication occurs. It has been shown that long-term prior treatment with inhaled Beta-agonists decreases the duration, but not the peak response, to short-term administration of the same agent. Increasing the frequency of aerosol administration or using continuous nebulization might be important in providing persistent bronchodilation in acutely ill patients who previously have been receiving long-term Beta-agonist therapy by inhalation. However, since studies suggest a relationship between the frequency of use of beta-agonists and increased mortality in asthmatics, care should be taken in prescribing the long term use of these medications. Prolonged bronchodilator therapy may be administered with a small volume nebulizer calibrated to deliver a known volume of solution at a specified flow rate. Prolonged therapy 1
is typically given over one (1) hour and may be repeated as ordered by a physician. V. Method: Large Volume Nebulizer (Heart Nebulizer) A. Equipment: 1. Heart Nebulizer. 2. Large bore aerosol tubing. 3. Oxygen supply tubing. 4. Flowmeter (oxygen or air), air compressor or O2 blender. 5. Medication as specified by physician's order. 6. 250 ml IV bag of saline. 7. IV pole. 8. EKG monitor. 9. Pulse oximeter. B. Procedure: 1. Check chart regarding order and collect necessary equipment. 2. Verify patient by checking identification bracelet, prepare patient/family for therapy by identifying yourself and explaining the procedure to the patient/family. 3. Vital signs (HR, RR), patient assessment (breath sounds, accessory muscle use), and pulse oximetry should be charted in the appropriate place in the patient record, initially and approximately every two hours thereafter. Monitor patient's EKG continuously. 4. Add prescribed amount of medication to Heart nebulizer. Dilute with IV normal saline to total volume of 150 cc. 5. Attach nebulizer to IV pole. Connect to flow meter with O2 supply tubing. 6. Connect large bore tubing to aerosol mask or tent. 7. Turn flowmeter on and adjust flow to 10 l/min for output of 30 ml/hr + or - 6 mls. If an O2 blender is used, adjust FIO2 to desired level. 8. Monitor medication solution, and repeat step #4 as needed (approximately 2
every 5 hours). Patient may receive 2 doses before physician re-evaluation is required. 9. If a change in dosage is required before all the solution has been used, re-dose and refill. 10. Change out the Heart Nebulizer, tubing and mask every 24 hours. 11. Daily weights should be taken on infants. VI. Method: Large Volume Nebulizer (Hope Nebulizer) A. Equipment: 1. Hope Nebulizer. 2. Large bore aerosol tubing. 3. Flowmeter (oxygen or air), air compressor or O2 blender. 4. Medication as specified by physician's order. 5. 250 ml IV bag of saline. 6. IV pole. 7. EKG monitor. 8. Pulse oximeter. B. Procedure: 1. Check chart regarding order and collect necessary equipment. 2. Verify patient by checking identification bracelet, prepare patient/family for therapy by identifying yourself and explaining the procedure to the patient/family. 3. Vital signs (HR, RR), patient assessment (breath sounds, accessory muscle use), and pulse oximetry should be charted in the appropriate place in the patient record, initially and approximately every two hours thereafter. Monitor patient's EKG continuously. 4. Add prescribed amount of medication to Heart nebulizer. Dilute with IV normal saline to total volume of 125 mls. 5. Attach nebulizer to IV pole. Connect to flow meter. 6. Connect large bore tubing to aerosol mask or tent. 7. Turn flowmeter on and adjust flow to 13 l/min for output of 25 ml/hr + or - 6 mls. If an O2 blender is used, adjust FIO2 to desired level. 8. Monitor medication solution, and repeat step #4 as needed (approximately 3
every 5 hours). Patient may receive 2 doses before physician re-evaluation is required. 9. If a change in dosage is required before all the solution has been used, re-dose and refill. 10. Change out the Hope Nebulizer, tubing and mask every 24 hours. 11. Daily weights should be taken on infants. VII. Method: Aerogen Nebulizer A. Equipment: 1. Aerogen solo nebulizer 2. Continuous nebulization tube set 3. Syringe infusion pump B. Procedure: 1. Ensure the Aeroneb Solo nebulizer unit is firmly fitted into the Aeroneb Solo T-piece in the breathing circuit. 2. Remove the syringe cap from the medication-filled syringe. 3. Attach the syringe end of the tubing onto the syringe. 4. Prime the tubing until the medication reaches end of tubing. NOTE: The tubing priming volume is maximum 3.65 ml. 5. Unplug the tethered cap from the Aeroneb Solo nebulizer, but do not remove it from the nebulizer. 6. Screw the nebulizer end of the tubing onto the top of the nebulizer. 7. Insert the syringe filled with medication into the syringe infusion pump. 8. Turn on the continuous mode option on the Aeroneb Pro-X control module (refer to Aeroneb Solo System instruction manual) and turn on the infusion pump (refer to pump manual or manufacturer for guidance. 9. Observe nebulizer for proper operation. During continuous nebulization, the nebulizer is on continuously and the medication is nebulized on a drop by drop basis. Nebulization should be visible with regular intermittent pauses. Medication level in the nebulizer reservoir should not rise during use. NOTE: The manufacturer s recommended input rate of medication into the Aeroneb Solo 4
nebulizer during continuous nebulization is 0.2mL per minute or 12 ml per hour. This is based on the manufacturer s specification for the lowest acceptable nebulizer flow rate. For directions on determining flow rates, refer to the Optional Flow Rate Calculation method. CAUTION: It is important to ensure that the maximum flow rate through the tube set into the nebulizer must not exceed the output rate of the nebulizer. OPTIONAL NEBULIZER FLOW RATE CALCULATION: Flow rates may vary between individual Aeroneb Solo nebulizers. The minimum flow rate for all Aeroneb Solo nebulizers is 0.2 ml per minute. In order to calculate the flow rate of an individual Aeroneb Solo nebulizer; follow these steps: 1. Transfer 0.5 ml of normal saline (0.9%) or intended drug into the Aeroneb Solo medication cup. 2. Turn on the nebulizer. 3. Using a stop-watch, measure the length of time it takes from the start of nebulization until all the saline/drug has been nebulized. 4. Calculate the flow rate using the following equations: Flow rate in ml/min= (Volume of normal saline or drug) x 60 Nebulization time in seconds Flow rate in ml/h = (Volume of normal saline or drug) x 60) x 60 Nebulization time in seconds VIII. Method: Prolonged Therapy (one hour) with medium or small volume nebulizer A. Equipment: 1. Medium volume nebulizer 2. Aerosol mask 5
3. Flowmeter (oxygen or air), air compressor or O2 blender. 4. Medication as specified by physician s order. 5. EKG monitor. 6. Pulse oximeter. B. Procedure: 1. Check chart regarding order and collect necessary equipment. 2. Verify patient and prepare patient/family for therapy by identifying yourself and explaining the procedure to the patient/family. 3. Vital signs (HR, RR), patient assessment (breath sounds, accessory muscle use), and pulse oximetry should be charted in the appropriate place in the patient record, initially and approximately every two hours thereafter. Monitor patient s EKG continuously. 4. Add prescribed volume of medication and diluents to nebulizer as defined on the nebulizer package insert to achieve dosage prescribed. 5. Attach nebulizer to gas source flowmeter. 6. Place aerosol mask on patient. 7. Turn flowmeter on and adjust flow to the output defined in the nebulizer package insert to deliver the full dosage in one (1) hour. If an O2 blender is used, adjust FIO2 to desired level. 8. Monitor vital signs and outcomes of therapy. 9. Re-dose nebulizer as ordered. IX. Special Considerations: A. DuoNeb (albuterol and ipratropium bromide) may be administered by prolonged therapy using unit dose medications, dosing in proportions related to the albuterol dose. Example: 15 mg per hour = 6 unit dose vials of DuoNeb. B. Levalbuterol may be given at ½ the albuterol dose. X. Documentation: 1. Document therapy in the Respiratory Therapy flowsheet. 2. Documentation should include date, time, FIO2, flow rate, medication, and dosage. 3. Chart "continuous aerosol" under duration. 6
4. Document initially and every 2-4 hours the patient s response to therapy: Breath sounds, heart rate, respiratory rate, accessory muscle use, cough effectiveness, sputum production and sputum characteristics, and SaO2. XI. Adverse Reactions: 1. Cardiac arrhythmias, primarily tachycardia when using beta adrenergic. 2. Nausea and vomiting. 3. Dizziness. 4. Hemoptysis. 5. Increased work of breathing. 6. Hyperoxygenation. Corrective Action: 1-5. Discontinue therapy, monitor patient and notify physician. 6. Use an O2 blender for precise FIO2. Monitor SaO2. DOSAGES FOR CONTINUOUS NEBULIZATION OF ALBUTEROL 0.5% (5mg/ml) LARGE VOLUME NEBULIZER (HEART NEBULIZER) METHOD (To be administered over 5 hours) WEIGHT ALBUTEROL Kg lbs. mls/150 mls mls/150 mls mls/150 mls (0.05mg/Kg/hr) (0.25mg/Kg/hr) (0.5mg/Kg/hr) <5 <11 0.25 ml 1.25 ml 2.5 ml 5-10 11-22 0.5 ml 2.5 ml 5 ml 10-20 22-44 1 ml 5 ml 10 ml 7
20-30 44-66 1.5 ml 7.5 ml 15 ml * MAXIMUM DOSAGE NOT TO EXCEED 15 MG/HR (15 ml TOTAL) FORMULA: Dosage mg/kg/hr X weight Kg X 5 hr/ 5mg/mL= mls of Albuterol to add to nebulizer and then bring total volume to 150 mls. DOSAGES FOR CONTINUOUS NEBULIZATION OF ALBUTEROL 0.5% (5mg/ml) LARGE VOLUME NEBULIZER (HOPE NEBULIZER) METHOD (To be administered over 5 hours) WEIGHT ALBUTEROL Kg lbs. mls/125 mls mls/125 mls mls/125 mls (0.05mg/Kg/hr) (0.25mg/Kg/hr) (0.5mg/Kg/hr) <5 <11 0.25 ml 1.25 ml 2.5 ml 5-10 11-22 0.5 ml 2.5 ml 5 ml 10-20 22-44 1 ml 5 ml 10 ml 8
20-30 44-66 1.5 ml 7.5 ml 15 ml * MAXIMUM DOSAGE NOT TO EXCEED 15 MG/HR (15 ml TOTAL) FORMULA: Dosage mg/kg/hr X weight Kg X 5 hr/ 5mg/mL= ml's of Albuterol to add to nebulizer and then bring total volume to 125 ml's. 9