The Science Journal of the American Association for Respiratory Care

2008 OPEN FORUM Abstracts


Darcy O'Brien-Genrich1, Edward Truemper2, Sue Clausen-Wright1

Background: The Nebraska Medical Center has incorporated an organizational Meter Dose Inhaler (MDI) titration protocol since 2004 for patients > 4 years of age. In the Pediatric Intensive Care Unit (PICU), the large number of patients below the minimum age limited protocol adoption. We undertook developing an MDI titration protocol for patients < 4 years of age. Medical literature was reviewed and a protocol was developed in 2007. The protocol incorporated titration of albuterol puffs administered in 4 puff aliquots using a range from 4 to 24 puffs/dose. Titration was based on the goal of relieving clinical evidence of bronchospasm. Prior to protocol implementation, an educational program for the pediatric critical care team was provided. Six months after implementation, we then assessed the success of protocol adoption and MDI dosing for the PICU population.

Data was extracted from the respiratory department information system to determine the number of PICU patients receiving the protocol six months after implementation. Of the patients who received titration, data was collected to determine the frequency, duration, number of puffs administered, and any significant increase in heart rate (>20%) while on the protocol.

Fifteen patients were placed on the protocol within six months of implementation and 11 of those patients were < 4 years of age. Patients were treated on protocol for an average of 14.2 days. MDI treatments were administered 96% of the time at scheduled intervals (most frequent every 4 hours) with only 4% of the treatments were administered prn. Fifty nine percent (N=1345) of the total number of treatments administered were more than the standard dose of 4 puffs of albuterol. The patients that received more than the standard dose averaged 14.5 puffs per treatment. No significant increase in heat rate documented regardless of the albuterol dose administered.

Our experience demonstrates the MDI titration protocol was successfully deployed after implementation. MDI doses as high as 24 puffs/treatment were well-tolerated; a dose not typically employed in pediatric patients. We recommend that developing and implementing an MDI titration protocol in critically ill pediatric patients incorporate an evidence-based analysis of current peer-reviewed literature; protocol development that involves all members of the ordering and dispensing team; and surveillance measures to ensure protocol adherence.