The Science Journal of the American Association for Respiratory Care

2006 OPEN FORUM Abstracts


Table 1: Treatment Types by Unit
Nursing Unit MDI % HHN %
Medical 72.7 27.3
Heme-Onc 63.3 36.7
Surgical 52.9 47.1
Total 71.7 28.3


conversion to Metered Dose Inhaler with Valved Holding Chamber (MDI-VHC) to administer inhaled bronchodilators in a pediatric hospital

John Salyer RRT, MBA, FAARC, Dave Crotwell RRT-NPS, Edward Carter MD. Respiratory Care Department, Children's Hospital and Regional Medical Center, Seattle WA. 

Background: Metered dose inhalers with valved holding chambers (MDI-VHCs) have been shown to be equivalent or better than hand-held nebulizers (HHN) for the delivery of bronchodilators in children.  At Seattle Children's Hospital we implemented the conversion from HHN to MDI-delivered bronchodilators in all non-intubated patients receiving intermittent treatments with inhaled albuterol.  Methods. The Aerochamber-Max VHC (Monaghan) was selected because of valve design, the anti-static polymer, and availability of different mask configurations.  Bronchodilator administration policy and asthma-bronchiolitis pathways were revised to recommend MDI-VHC use in lieu of HHN.  Physician order sets were amended to indicate MDI-VHC as the preferred method of delivering aerosolized bronchodilators in children with asthma or bronchiolitis. Dosing equivalency for albuterol via HHN versus MDI-VHC was established as 2.5 mg of albuterol by HHN = 4 puffs by MDI, and 5 mg by HHN = 8 puffs by MDI. The conversion was advertised in various hospital publications, and informational packets were available to community MD's upon request. Both nurses and RTs were informed of the proposed conversion via lectures, printed materials, and small group in-services.  MDI-VHC training was made part of standard nursing skills training. VHC's were added to the supply distribution system (Omni-cell). Approximately six months after implementation we analyzed changes in the method of delivery of inhaled albuterol using an electronic medication administration record. 

Table 2:  Supply and Labor Costs of 12 Treatments
  HHN MDI-VHC
Supply Costs $7.45 $16.10
Labor Costs $159.00 $102.96
Total Costs $166.45 $119.06



Results: Before the MDI conversion project, nearly 100% of albuterol treatments were delivered by HHN. After the implementation we evaluated 3467 albuterol treatments given between May and October 2005 on pediatric wards; 2485 (71.7%) were administered via MDI-VHC vs. 982 (28.3%) by HHN.  Table 1 lists the distribution of delivery method by nursing unit.  Using our productivity measurement system we spent 35% less time to administer albuterol via MDI-VHC compared to HHN, 13 minutes and 20 minutes respectively. However, the supply cost of an MDI-VHC was slightly higher.  Using respiratory labor and supply/medication cost modeling of a single admission with 12 treatments, based on our cost structure albuterol delivery with the MDI-VHC was less costly than with the HHN (Table 2).  The average length of hospital stay (LOS) for patients with asthma has been steadily decreasing since 2002 and this trend continued after the implementation of this conversion program.  2002 LOS = 2.05 days, 2005 LOS = 1.52 days. 

Discussion: We successfully implemented the conversion from HHN to MDI-VHC for the delivery of inhaled albuterol. Since implementing the conversion, our respiratory therapy operating cost per respiratory therapy workload unit (relative value unit) has decreased by15% after adjustment for inflation.  We speculate that our MDI conversion program made a significant contribution to this reduced cost structure, as well as other factors. It has been reported that families preferred MDI to HHN (Pediatr 2000; 106:311-317) and this has also been our experience.

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Table 1: Treatment Types by Unit
Nursing Unit MDI % HHN %
Medical 72.7 27.3
Heme-Onc 63.3 36.7
Surgical 52.9 47.1
Total 71.7 28.3


conversion to Metered Dose Inhaler with Valved Holding Chamber (MDI-VHC) to administer inhaled bronchodilators in a pediatric hospital