Reprinted from the December 1995 issue of RESPIRATORY CARE [Respir Care 1995;40(12):1300–1307]
AARC Clinical Practice Guideline
Assessing Response to Bronchodilator Therapy at Point of Care
ARBD 1.0 PROCEDURE:
Assessing response in adults and older children* to aerosolized bronchodilator therapy at the point of care. Although subjective responses and changes in mucociliary activity are important bronchodilator therapy effects, this guideline emphasizes the airway smooth muscle response that is primarily quantified through measurement of pulmonary function. It does not address initial diagnostic or ongoing (longitudinal) laboratory evaluation. A future Guideline will address assessment during mechanical ventilation.
*For assessing responses in infants and toddlers, see AARC CPG Infant/Toddler PFT.(1)
ARBD 2.0 DESCRIPTION:
- 2.1 Assessment of airflow (ie, forced expiratory maneuvers and other clinical indicators) is important to determine the presence or absence of an immediate response (ie, at time of expected onset of effect), proper dose, frequency of administration, and overall response to long-term therapy). It is essential that the clinician have complete knowledge of the main effects, mode of action, time course, side effects, and dosage constraints of any medications administered.
- 2.2 This guideline addresses
- 2.2.1 subjective and objective measures of response;
- 2.2.2 frequency of monitoring;
- 2.2.3 expected or desirable outcomes.
ARBD 3.0 SETTINGS:
- 3.1 Critical care
- 3.2 Acute care
- 3.3 Extended care or skilled care facility
- 3.4 Outpatient clinic
- 3.5 Home
- 3.6 Pulmonary rehabilitation program
ARBD 4.0 INDICATIONS:
Assessment of airflow and other clinical indicators are indicated when the need exists
- 4.1 to confirm the appropriateness of therapy;(2-4)
- 4.2 to individualize the patient's medication dose per treatment and/or frequency of administration;(2-7)
- 4.3 to help determine patient status during acute and long-term pharmacologic therapy;(2,8-10)
- 4.4 to determine a need for change in therapy (dose, frequency, or type of medication).(2,11)
ARBD 5.0 CONTRAINDICATIONS:
When patients present in acute, severe distress, some assessment maneuvers may be contraindicated or should be postponed until therapy (eg, bronchodilator treatment) and supportive measures (eg, oxygen therapy) have been instituted.
ARBD 6.0 HAZARDS/COMPLICATIONS:
Hazards and complications include
- 6.1 those associated with deep inhalation and forced exhalation
- 6.1.1 bronchoconstriction(12,13)
- 6.1.2 airway collapse(14)
- 6.1.3 paroxysmal coughing with or without syncope;(15,16)
- 6.2 inherent hazards or complications of specific assessment procedures (ie, arterial puncture, esophageal balloons, forced exhalations).(16,17)
ARBD 7.0 LIMITATIONS OF PROCEDURE OR DEVICE:
- 7.1 Conventional spirometry:
- 7.1.1 cost and accessibility
- 7.1.2 the patient's inability to perform forced vital capacity.
- 7.2 Peak-flow measurement
- 7.2.1 Patient's inability to perform peak-flow maneuver or forced expiration.
- 7.2.2 The accuracy and reproducibility of peak-flow meters may vary among models and among units of the same model.(2,18-22)
- 18.104.22.168 For consistency and reproducibility of results the same device (unit) should be used for a given patient.(2,21)
- 22.214.171.124 If peak-flow meter is changed, the patient's range should be re-established because of variability among units and models.
- 126.96.36.199 Peak flow measurement primarily reflects changes in upper airway conductance and may be of limited use in evaluation of changes in peripheral airway conductance.(23,24)
- 188.8.131.52 Evaluation of peak flow performance is subjective,(25) and, therefore, acceptability criteria are lacking. Because the maneuver is effort and volume dependent, the patient must be encouraged to perform as vigorously as clinically feasible (Three trials are desirable, with the best reported). Nose clips are not necessary, and the standing position is preferred.
- 7.3 The results of subjective evaluation may be difficult to interpret consistently. A validated dyspnea rating scale may be useful.(26-30)
- 7.3.1 Breath sound interpretation(31-34)
- 7.3.2 Symptoms (eg, dyspnea)(27-29)
- 7.4 The presence of an artificial airway increases resistance and, thus, increases work of breathing in the spontaneously breathing patient and may limit inspiratory and expiratory flows.(35,36)
- 7.5 Techniques for monitoring response to bronchodilator in intubated, mechanically ventilated patients are different (eg, the flow-volume curve generated through an intubated airway may be difficult to interpret).(37-40) Accuracy and reproducibility of results may be affected by the mental and physical condition of the patient.(41) The measurement technology and, therefore, the results may vary from ventilator to ventilator.(40) Bronchodilator administration and assessment of response in the MV patient will be further addressed in a separate guideline.
ARBD 8.0 ASSESSMENT OF NEED
- 8.1 Response to therapy should be evaluated in all patients receiving bronchodilator therapy. (However, patient's in severe distress may need immediate treatment that precludes establishing a quantitative baseline).
- 8.2 Assessment of response must be made with due regard for the patient's history, clinical presentation, and results of physical exam.
ARBD 9.0 ASSESSMENT OF OUTCOME
Assessment of outcome answers the question How did assessment of the effect of bronchodilator therapy impact on patient management?
- 9.1 Action based on results of assessment
- 9.1.1 Increase or decrease in dose and/or frequency
- 9.1.2 Change medications
- 9.1.3 Add medications
- 9.1.4 Continue regimen
- 9.1.5 Discontinue therapy
- 9.2 To guide patient management, baseline condition and changes from baseline must be determined
- 9.2.1 Prior to therapy:
- 184.108.40.206 establish respiratory and cardiovascular baseline values;
- 220.127.116.11 establish presence of clinical indicators and need for therapy;
- 18.104.22.168 identify presence of contraindications.
- 9.2.2 During therapy, identify:
- 22.214.171.124 adverse responses to medication;
- 126.96.36.199 any clinical change from baseline.
- 9.2.3 Following therapy, identify:
- 188.8.131.52 adverse responses;
- 184.108.40.206 therapeutic responses (time course for peak varies with different medications);
- 220.127.116.11 lack of therapeutic response.
- 9.2.4 For trend analysis, identify:
- 18.104.22.168 change in patient baseline;
- 22.214.171.124 need to modify dose;
- 126.96.36.199 need to change therapy;
- 188.8.131.52 need to discontinue therapy;
- 184.108.40.206 direction of change in bronchial responsiveness.
- 9.3 Documentation:
- 9.3.1 Patient response to medication
- 220.127.116.11 Medication type, dose, and time received
- 18.104.22.168 Responses measured: vital signs, breath sounds, lung function (eg, PEFR, FEV1, FEV1/.FVC), dyspnea score(26-29)
- 22.214.171.124 Relate observations to time of medication administration and expected time of onset and peak response.
- 9.3.2 Patient's progress
- 9.3.3 Ability to self-assess and to recognize the need for more aggressive therapy and when and how to communicate with health professional.
- 9.3.4 Record of symptoms and concurrent PEFR measurements should be kept for or by the patient at home.(2,42,43)
ARBD 10.0 RESOURCES:
- 10.1 Equipment and other aids
- 10.1.1 Instruments to measure expiratory flows: the choice of devices is based on cost, availability, and portability. When a portable laboratory spirometer that meets ATS standards(16,44) is available it should be used because results yield more information than is available from peak-flow measurement alone.
- 10.1.1.1 Conventional spirometry with forced expiratory maneuvers is the standard for diagnostic measurement of bronchodilator response.(2,16,44)
- 10.1.1.2 Peak flow measurement can be used for pre- and post-treatment measurement and for daily and trend monitoring.(2,8,45,46)
- 10.1.2 Stethoscope
- 10.1.3 Pulse oximeter
- 10.1.4 Structured interview form for complete history; validated dyspnea indices.(2)
- 10.1.5 Materials for patient and family education and diary(2,42,43)
- 10.2 Resources--Personnel:
- 10.2.1Level II personnel--licensed or credentialed respiratory care practitioners (eg, RRT,(47) RPFT,(48) CPFT,(49) CRTT(50)) or persons with equivalent knowledge, training, and ability, who have documented that knowledge and demonstrated the necessary skills:
- 10.2.1.1 to perform initial assessments and care for the unstable patient;
- 10.2.1.2 to assess patient condition and response to therapy;
- 10.2.1.3 to identify the indications for and effects of specific medication and equipment;
- 10.2.1.4 to instruct patients in proper breathing patterns and coughing techniques;
- 10.2.1.5 to modify therapy and appropriately care for the patient in response to adverse reactions;
- 10.2.1.6 to modify dose, frequency, or delivery method or to change medication according to the patient's response, within the constraints of the protocol or the physician's direction;
- 10.2.1.7 to use proper technique for administration of aerosols;
- 10.2.1.8 to perform, interpret, and document conventional spirometry, peak expiratory flowrate, and ventilatory mechanics and to perform and document auscultation, inspection and assessment of vital signs, and
- 10.2.1.9 to teach proper use of symptom diary and peak-flow meter;
- 10.2.1.10 to develop, teach, and assess self-care plan for patient and family care giver;
- 10.2.1.11 to properly use equipment, administer treatment, and make assessment in compliance with Universal Precautions and other infection-control procedures.(51,52)
- 10.2.2 Level I personnel--licensed or credentialed respiratory care practitioners (eg, RRT,(47) RPFT,(48) CPFT,(49) CRTT(50)) or persons with equivalent knowledge, training, and ability, who have documented that knowledge and demonstrated the necessary skills:
- 10.2.2.1 to observe, measure, monitor, and document response variables established with the patient's care plan (eg, use of diary and peak flow meter);
- 10.2.2.2 to use proper technique for administration of medication;
- 10.2.2.3 to properly use and clean equipment;
- 10.2.2.4 to instruct patients in proper breathing patterns and coughing techniques;
- 10.2.2.5 to modify therapy and patient care (within the constraints of the protocol or physician's directions) in response to changes in monitored variables, severity of symptoms, or adverse reactions and to communicate any modifications to Level-II provider or physician;
- 10.2.2.6 to properly use equipment, administer treatment, and make assessment in compliance with Universal Precautions and other infection-control procedures.(51,52)
- 10.2.3 Patient or family/caregiver providing maintenance therapy must know and demonstrate ability:
- 10.2.3.1 to monitor or measure response to bronchodilator in accordance with the patient's care plan (use of symptom diary and peak-flow meter);(2,42,43)
- 10.2.3.2 to use proper technique for administration of medication and correct use of devices (eg, MDI, spacer, peak-flow meter, small volume nebulizer);(2,7,43)
- 10.2.3.3 to properly use and clean equipment;
- 10.2.3.4 to modify doses and frequency as prescribed and instructed in response to adverse reactions or increase in severity of symptoms and to appropriately communicate with physician regarding severity of symptoms.
ARBD 11.0 MONITORING:
Monitoring seeks to establish baseline function and reveal the presence or absence of a desirable response to bronchodilator or other airway medication and to identify changes in airway reactivity in response to allergens, exercise, infection, or other causes. Desirable responses are:
- 11.1 From observation of the patient
- 11.1.1 General appearance is improved.
- 11.1.2 Use of accessory muscles is decreased.
- 11.1.3 Sputum expectoration is increased.
- 11.2 From auscultation
- Breath sounds may be improved, with a decrease in wheezing(2-5) or adventitious breath sounds and the volume of air moved is increased. (Decreased wheezing, eg, the 'silent' chest coupled with decreased volume of air moved can be an indication of a worsening condition rather than improvement.)
- 11.3 Vital signs are more nearly normal.(53-55)
- 11.4 Patient reports improvement(18,29,30)(eg, less dyspneic(56,57))
- 11.5 From pulmonary function measurement: It is important to note that although correlation is generally high between values obtained by conventional spirometry and measurement of PEF, agreement may be poor for individual patients.(24,34,58)
- 11.5.1 FEVl, FVC,(2,7,58-61) and/or FEF25-75%(2,58,60) are improved.
- Note: The ATS standards for a positive bronchodilator response in adults is "12% increase, calculated from the prebronchodilator response values,and a 200-mL increase in either FVC or FEV1."(62) Dynamic compression of the airways during forced maneuvers may mask bronchodilator response in some patients, and for these patients the additional measurement of airway resistance and calculation of specific conductance may provide more diagnostic evidence.
- 11.5.2 PEF(2,7,58,60,63) is increased.
- Note: National Asthma Education and Prevention (NAEPP) Guidelines(2) provide detailed directions for use of the PEF in the asthmatic population.
- 11.6 SaO2 (or SpO2),(2) and/or arterial blood gas values are improved (Effects of underlying chronic respiratory, metabolic, or other condition should be considered.)
- 11.7 Exercise performance is improved as reflected by a more normal PEF during exercise or immediately following(63) or an increase in distance achieved during the 6-minute walking test(59)
- 11.8 Ventilator variables are improved.(38-40,64)
- 11.8.1 Lower PIP (during volume ventilation)
- 11.8.2 Lower plateau pressure, increased static lung compliance.
- 11.8.3 Decreased inspiratory and expiratory resistance
- 11.8.4 Increased expiratory flow, improved flow-volume loop
- 11.8.5 Decreased auto-PEEP
ARBD 12.0 FREQUENCY
- 12.1 Acute unstable patient:
- 12.1.1 Whenever possible, perform a full assessment and obtain a pretreatment baseline.
- 12.1.2 Perform arterial blood gas analysis on admission if patient is in severe distress.(2)
- 12.1.3 Assess and document all appropriate variables before and after each treatment, (breath sounds, vital signs, side effects during therapy, PEF or FEVl.(2)
- 12.1.4 The frequency with which physical exam, PEF, and/or FEV1 are repeated should be based on the acuteness and severity of the patient's condition.
- 12.1.5 SpO2 should be monitored continuously, if possible.(2)
- 12.1.6 Assessment should continue at each level of medication dose to optimal response for patient(5) (eg, asthmatic patient achieves 70-90% of predicted or "personal best" or is symptom free(2))
- 12.2 Stable patient:(43,65)
- 12.2.1 In the hospital setting, the PEF should be measured initially before and after each bronchodilator administration--to establish baseline function and to determine relative changes in function. Thereafter, twice daily determinations may be adequate.
- 12.2.2 In the home, use the PEF 3-4 times a day (on rising, noon, 4-7 pm, and at bedtime)(2,66) to establish baseline function and to determine relative changes in function.
- 126.96.36.199 For the stable COPD patient at home, twice a day measurements may be adequate.
- 188.8.131.52 Asthmatic patients in the home will need to adjust the frequency of peak flow measurement according to their level of severity, with the development of symptoms, or with any deviation from baseline. Twice daily measurements (about 7 am and 7 pm) are recommended for routine monitoring--(variability between these two measurements is a measure of severity.(2))
- 12.2.3 The pre- and postbronchodilator PEFRs, medication dosage, date and time, and the dyspnea score should be documented.
- 12.2.4 The patient should be periodically re-evaluated for response to therapy.
ARBD 13.0 INFECTION CONTROL:
Aerosol Therapy Focus Group
- 13.1 Universal Precautions(47) and precautions related to the spread of tuberculosis as published by the Centers for Disease Control(48) should be followed.
- 13.2 All equipment and supplies should be appropriately disposed of or subjected to high-level disinfection between patients.(67)
Jon O Nilsestuen PhD RRT, Chairman, Galveston TX
James Fink MS RRT, Hines IL
Theodore Witek Jr DrPH RPFT RRT, Ridgefield CT
James Volpe III RRT MEd, San Diego CA
- American Association for Respiratory Care. AARC Guideline: infant/toddler pulmonary function tests. Respir Care 1995;40(7):761-768.
- National asthma education program--expert panel report. Guidelines for the diagnosis and management of asthma. NIH publication 91-3042A, June 1991.
- McNamara RM, Cionni DJ. Utility of the peak expiratory flow rate in the differentiation of acute dyspnea: cardiac vs pulmonary origin. Chest 1992;101(1):129-132.
- Charan NB, Carvalho P. Cardinal symptoms in respiratory disease. In: Pierson DJ, Kacmarek RM, eds. Foundations of respiratory care. New York: Churchill Livingstone, 1992:199-201.
- Tashkin DP. Dosing strategies for bronchodilator aerosol delivery. Respir Care 1991;36(9):977-988.
- Schuh S, Parkin P, Rajan A, Canny G, Healy R, Rieder M, et al. High- versus low-dose, frequently administered, nebulized albuterol in children with severe, acute asthma. Pediatrics 1989;83(4):513-518.
- American Association for Respiratory Care. Aerosol Consensus Statement--1991. Respir Care 1991;36(9): 916-921.
- Bellia V, Visconti A, Insalaco G, Cuttitta G, Ferrara G, Bonsignore G. Validation of morning dip of peak expiratory flow as an indicator of the severity of nocturnal asthma. Chest 1988;94(1):108-110.
- Mitchell DM, Gildeh P, Dimond AH, Collins JV. Value of serial peak expiratory flow measurements in assessing treatment response in chronic airflow limitation. Thorax 1986;41(8):606-610.
- Shim CS, Williams MH Jr. Evaluation of the severity of asthma: patients versus physicians. Am J Med 1980; 68(1)11-13.
- Shim CS, Williams MH Jr. Relationship of wheezing to the severity of obstruction in asthma. Arch Intern Med 1983;132(5):890-892.
- Lim TK, Ang SM, Rossing TH, Ingenito EP, Ingram RH. The effects of deep inhalation on maximal expiratory flow during intensive treatment of spontaneous asthmatic episodes. Am Rev Respir Dis 1989; 140:340-343.
- Lemarchand P, Labrune S, Herer B, Huchon GJ. Cardiorespiratory arrest following peak expiratory flow measurement during attack of asthma. Chest 1991;100(4):168-169.
- Stanescu DC, Teculescu DB. Exercise- and cough-induced asthma. Respiration 1970;27(4):377-383.
- Stern RC, Horwitz SJ, Doershuk CF. Neurologic symptoms during coughing paroxysms in cystic fibrosis. J Pediatr 1988;112(6):9099-912.
- American Association for Respiratory Care. AARC Guideline: Spirometry. Respir Care 1991;36:1414-1417.
- American Association for Respiratory Care. AARC Guideline: Sampling for arterial blood gas analysis. Respir Care 1992;37(8):913-917.
- Lebowitz MD. The use of peak expiratory flow rate measurements in respiratory disease. Pediatr Pulmonol 1991;11:166-174.
- van Schayck CP, Dompeling E, van Weel C, Folgering H, van den Hoogen HJ. Accuracy and reproducibility of the Assess peak flow meter. Eur Respir J 1990;3(3):338-341.
- Jones KP, Mullee MA. Measuring peak expiratory flow in general practice: comparison of mini Wright peak flow meter and turbine spirometer. BMJ 1990;300 (6740):1629-1631.
- Simmons M, Wynegar T, Hess D. Evaluation of the agreement between portable peak flow meters and a calibrated pneumotachometer. Respir Care 1993;38 (8):916-922.
- Pedersen OF, Miller MR, Sigsgaard T, Tidley M, Harding RM. Portable peak flow meters: physical characteristics, influence of temperature, altitude, and humidity. Eur Respir J 1994;7(5):991-997.
- Johns DP, Abramson M, Bowes G. Evaluation of a new ambulatory spirometer for measuring forced expiratory volume in one second and peak expiratory flow rate. Am Rev Respir Dis 1992;147:1245-1250.
- Bérubé D, Cartier A, L'Archevêque J, Ghezzo H, Malo J-L. Comparison of peak expiratory flow rate and FEV1 in assessing bronchomotor tone after challenges with occupational sensitizers. Chest 1991;99(4):831-836.
- American Thoracic Society, Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. Crapo RO, chairman. Standardization of spirometry--1994 update. Am J Respir Crit Care Med 1995; 152;1107-1136.
- Mahler DA, Weinberg DH, Wells CK, Feinstein AR. The measurement of dyspnea: contents, interobserver agreement, and physiologic correlates of two new clinical indexes. Chest 1984;85(6):751-758.
- Stoller JK. Ferranti R, Feinstein AR. Further specification and evaluation of a new clinical index for dyspnea. Am Rev Respir Dis 1986;134:1129-1134.
- Mahler DA, Harver A. A factor analysis of dyspnea ratings, respiratory muscle strength, and lung function in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1992;145:467-470.
- Turner TR, Corkery KJ, Ecleman D, Gelb AM, Lipavsky A, Sheppard D. Equivalence of continuous flow nebulizer and metered-dose inhaler with reservoir bag for treatment of acute airflow obstruction. Chest 1988;93(3):476-481.
- Berry RB, Shinto RA, Wong FH, Despers JA, Light RW. Nebulizer vs spacer for bronchodilator delivery in patients hospitalized for acute exacerbation of COPD. Chest 1989;96(6):1241-1246.
- Wilkins RL, Dexter JR, Smith JR. Survey of adventitious lung sound terminology in case reports. Chest 1984;85(4):523-525.
- Burki NK, Mitchell K, Chaudhary BA, Zechman FW. The ability of asthmatics to detect added resistive loads. Am Rev Respir Dis 1978;117;71-75.
- Sly PD, Landau LI, Weymouth R. Home recording of peak expiratory flow rates and perception of asthma. Am J Dis Child 1985;139(5):479-482.
- Burdon JGW, Juniper EF, Killian KJ, Hargreave FE, EJM Campbell. The perception of breathlessness in asthma. Am Rev Respir Dis 1982;126:825-828.
- Habib MP. Physiologic implications of artificial airways. Chest 1989;96(1):180-184.
- Sharar SR. The effects of artificial airways on airflow and ventilatory mechanics: basic concepts and clinical relevance. Respir Care 1995;40(3):257-262.
- Gottfried SB, Rossi A, Higgs BD, Calverley PMA, Zocchi L, Bozic C, Milic-Emili J. Noninvasive determination of respiratory system mechanics during mechanical ventilation for acute respiratory failure. Am Rev Respir Dis 1985;131(3):414-420.
- Gay PC, Rodarte JR, Tayyab M, Hubmayr RD. Evaluation of bronchodilator responsiveness in mechanically ventilated patients. Am Rev Respir Dis 1987;136(4):880-885.
- Hess D. The delivery of aerosolized bronchodilator to mechanically ventilated intubated adult patients (editorial) Respir Care 1990;35(5): 399-404.
- Kacmarek RM, Hess D. The interface between patient and aerosol generator. Respir Care 1991;36(9):952-976.
- Criner GJ, Isaac L. Psychological issues in the ventilator-dependent patient. Respir Care 1995;40(8):855-865.
- Hetzel MR, Williams IP, Shakespeare RM. Can patients keep their own peak-flow records reliably? Lancet 1979; 1(8116):597-599.
- Ignacio-Garcia JM, Gonzalez-Santos P. Asthma self-management education program by home monitoring of peak expiratory flow. Am J Respir Crit Care Med 1995; 151:353-359.
- American Thoracic Society. Standardization of spirometry--1987 update. Am Rev Respir Dis 1987;136:1285-1298. Printed concurrently in Respir Care 1987;32: 1039-1060.
- Enright PL, Sherrill DL, Lebowitz MD. Ambulatory monitoring of peak expiratory flow: Reproducibility and quality control. Chest 1995;107:657-661.
- Quakenboss JJ, Lebowitz MD, Krzyzanowski M. The normal range of diurnal changes in peak expiratory flow rates: relationship to symptoms and respiratory disease. Am Rev Respir Dis 1991;143:323-330.
- National Board for Respiratory Care. NBRC 1994 Study Guide--RRT examination. Shawnee Mission KS: National Board for Respiratory Care, 1994.
- National Board for Respiratory Care. NBRC 1994 Study Guide--RPFT examination. Shawnee Mission KS: National Board for Respiratory Care, 1994.
- National Board for Respiratory Care. NBRC 1994 Study Guide--CPFT examination. Shawnee Mission KS: National Board for Respiratory Care, 1994.
- National Board for Respiratory Care. NBRC 1994 Study Guide--CRTT examination. Shawnee Mission KS: National Board for Respiratory Care, 1994.
- Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR 1988;37:377-382,387-388.
- Centers for Disease Control. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related tissues. MMWR 1990;39(RR-17):1-29.
- Gravelyn TR, Weg JG. Respiratory rate as an indicator of acute respiratory dysfunction. JAMA 1980;244 (10):1123-1125.
- McFadden JP, Price RC, Eastwood HD, Briggs RS. Raised respiratory rate in elderly patients: a valuable physical sign. BMJ 1982;284(6316):626-627.
- Browning IB, D'Alonzo GE, Tobin MJ. Importance of respiratory rate as an indicator of respiratory dysfunction in patients with cystic fibrosis. Chest 1990;97 (6):1317-1321.
- Newhouse MT, Dolovich MB. Aerosol therapy of reversible airflow obstruction--concepts and clinical applications. Chest 1987;91(5,suppl)58-64.
- Toogood JH. Helping your patients make better use of MDIs and spacers. J Respir Dis 1994 15:2:151-164.
- Meltzer AA, Smolensky MH, D'Alonzo GE, Harris RB, Scott PH. An assessment of peak expiratory flow as a surrogate measurement of FEV1 in stable asthmatic children. Chest 1989;96(2):329-333.
- Mestitz H, Copland JM, McDonald CF. Comparison of outpatient nebulized vs metered dose inhaler terbutaline in chronic air flow obstruction. Chest 1989;96(6): 1237-1240.
- Cissik JH, Bode FR, Smith JA. Double-blind crossover study of five bronchodilator medications and two delivery methods in stable asthma: is there a best combination for use in the pulmonary laboratory? Chest 1986;90:(4):489-493.
- Shim CS, Williams MH Jr. Effect of bronchodilator therapy administered by canister versus jet nebulizer. J Allerg Clin Immunol 1984;73(3):387-390.
- American Thoracic Society. Lung function testing: selection of reference values and interpretive strategies. Am Rev Respir Dis 1991;144(5):1202-1218.
- Jenkins SC, Heaton RW, Fulton TJ, Moxham J. Comparison of domiciliary nebulized salbutamol and salbutamol from a metered-dose inhaler in stable chronic airflow limitation. Chest 1987;91(6):804-807.
- Fernandez A, Lazaro A, Garcia A, Aeagon C, Cerda E. Bronchodilators in patients with chronic obstructive pulmonary disease on mechanical ventilation: utilization of metered-dose inhalers. Am Rev Respir Dis 1990;141: 164-168.
- Reddel HK, Salome CM, Peat JK, Woolcock AJ. Which index of peak expiratory flow is most useful in the management of stable asthma? Am J Respir Crit Care Med 1995;151:1320-1325.
- Harm DL, Kotses H, Creer TL. Improving the ability of peak expiratory flow rates to predict asthma. J Allergy Clin Immunol 1985;76(5):688-694.
- Ahmed J, Brutus A, D'Amato RF, Glatt AE.Acinetobacter calcoaceticus anitratus outbreak in the intensive care unit traced to a peakflow meter. Am J Infect Control 1994;22(5):319-321.
Adelroth E, Hargreave FE, Ramsdale EH. Do physicians need objective measurements to diagnose asthma? Am Rev Respir Dis 1986;134(4):704-707.
Anderson SD, Silverman M, Konig P, Godfrey S. Exercise-induced asthma. Br J Dis Chest 1975;69(1):1-39.
Bolder PM, Healy TE, Bolder AR, Beatty PC, Kay B. The extra work of breathing through adult endotracheal tubes. Anesth Analg 1986;65(8):853-859.
Ba M, Spier S, Lapierre G, Lamarre A. Wet nebulizer versus spacer and metered dose inhaler via tidal breathing. J Asthma 1989;26(6):355-358.
Bersten AD, Rutten AJ, Vedig AE, Skrowronski GA. Additional work of breathing imposed by endotracheal tubes, breathing circuits, and intensive care ventilators. Crit Care Med 1989;17(7):671-677.
Clark NM, Evans, Melllins RB. Patient use of peak flow monitoring. Am Rev Respir Dis 1992;145:722-725.
Comstock GW, Tockman MS, Hesing KJ, Hennesy KM. Standardized respiratory questionnaires: comparison of the old with the new. Am Rev Respir Dis 1979; 119(1)45-53.
Cook NR, Evans DA, Scherr PA, Speizer FE, Vedal S, Branch LG, et al. Peak expiratory flow rate in an elderly population. Am J Epidemiol 1989;130(1):66-78.
Eichenhom MS, Beauchamp RK, Harper PA, Ward JC. An assessment of three portable peak flow meters. Chest 1982;82(3):306-309.
Fernandez R, Sole J, Blanch L, Artigas A. The effect of short-term instillation of a mucolytic agent (Mesna) on airway resistance in mechanically ventilated patients. Chest 1995;107(4):1101-1106.
Gal TJ, Suratt PM. Resistance to breathing in healthy subjects following endotracheal intubation under topical anesthesia. Anesth Analg 1980;59(4):270-274.
Gautrin D, D'Aquino LC, Gagnon G, Malo J-L, Cartier A. Comparison between peak expiratory flow rates (PEFR) and FEV1 in the monitoring of asthmatic subjects at an outpatient clinic. Chest 1994;106(5):1419-1426.
Gay PC, Patel HG, Nelson SB, Gilles B, Hubmayr RD. Metered dose inhalers for bronchodilator delivery in intubated mechanically ventilated patients. Chest 1991;99(1)66-71.
Godfrey S. Exercise-induced asthma--clinical, physiological, and therapeutic implications. J Allergy Clin Immunol 1975;56(1):1-17.
Godfrey S, Konig P. Suppression of exercise-induced asthma by salbutamol, theophylline, atropine, cromolyn, and placebo in a group of asthmatic children. Pediatrics 1975;56(5, Part 2, suppl):930-934.
Godfrey S. Exercise-induced asthma-clinical physiological, and therapeutic implications. J Allergy Clin Immunol 1975;56(1):1-17.
Gupta CK, Mathur N. Statistical models relating peak expiratory flow rates to age, height, and weight in men and women. J Epidemiol Community Health 1982;36(1):64-67.
Harm DL, Marion RJ, Creer TL, Kotses H. Effects of instructions on pulmonary function values. J Asthma 1985;22 (6):289-294.
Kelly CA, Gibson GJ. Relation between FEV1 and peak expiratory flow in patients with chronic airflow obstruction. Thorax 1988;43(4):335-336.
Levinson H, Reilly PA, Worsley GH. Spacing devices and metered-dose inhalers in childhood asthma. J Pediatr 1985; 107(5):662-668.
Marini JJ, Rodriguez RM, Lamb V. Chest 1986;89(1):56-63.
Marini JJ. Dyspnea during weaning. Respir Care 1995;40 (3):271-276.
Melville C, Phelan PD, Landau LI. Nebulized fenoterol compared with metered aerosol. Arch Dis Child 1985;60 (3):257-259.
Morgan MDL, Singh BV, Frame MH, Williams SJ. Terbutaline aerosol given through pear spacer in acute severe asthma. BMJ 1985;285(6345):849-850.
O'Callaghan C, Milner AD, Swarbrick A. Spacer device with face mask attachment for giving bronchodilators to infants with asthma. BMJ 1989;298(6667):160-161.
O'Reilly JF, Gould G, Kendrick AH, Laszlo G. Domiciliary comparison of terbutaline treatment by metered dose inhaler with and without conical spacer in severe and moderately severe chronic asthma. Thorax 1986;41(10):766-770.
Pollack CV Jr. Utilization of the peak expiratory flow rate in evaluation of acute dyspnea of cardiac or pulmonary origin (letter). Chest 1993;103(4):1306-1307.
Ramsdale EH, Morris MM, Hargreave FE. Interpretation of peak flow rates in chronic bronchitis. Thorax 1986;41 (10):771-776.
Shapiro M, Wilson RK, Casar G, Bloom K, Teague RB. Work of breathing through different sized endotracheal tubes. Crit Care Med 1986;14(12):1028-1031.
Thomas P, Pugsley JA, Stewart JH. Theophylline and salbutamol improve pulmonary function in patients with chronic obstructive pulmonary disease. Chest 1992;101(1):160-165.
Venables KM. Burges PS, Davison AG, Newman-Taylor AJ. Peak flow rate records in surveys: reproducibility of observers' reports. Thorax 1984;39(11):828-832.
Volpe J, Kendall H, Gilbert D, Stowe B, Dundovich K. Metered dose inhalers. RT 1990;3(3):18-23.
Weissman C, Askanazi J, Rosenbaum SH, Damask MC, Hyan AI. Kinney JM. Response to tubular airway resistance in normal subjects and postoperative patients. Anesthesiology 1986;64(3):353-358.
Wright PE, Marini JJ, Bernard GR. In vitro versus in vivo comparison of endotracheal tube airflow resistance. Am Rev Respir Dis 1989;140(1):10-16.
Wu RS, Wu KC, Tsai YH, Cheng RK, Tan PP. Inhaled fenoterol pretreatment attenuates airway resistance response to endotracheal intubation. Acta Anaesthesiol Sin 1995;33(1):7-14.
Zandstra DF, Stoutenbeek CP, Miranda Dr. Effect of mucolytic and bronchodilator aerosol therapy on airway resistance in mechanically ventilated patients. Intensive Care Med 1985;11(6):316-318.
Zureik M, Liard R, Segala C, Henry C, Korobaeff M, Neukirch F. Peak expiratory flow rate variability in population surveys: does the number of assessments matter. Chest 1995;107:418-423.
Interested persons may copy these Guidelines for noncommercial
purposes of scientific or educational advancement. Please credit AARC and Respiratory
Reprinted from the December 1995 issue of RESPIRATORY CARE [Respir Care 1995;40(12):1300–1307]