Reprinted from the August 1994 issue of RESPIRATORY CARE [Respir Care 1994; 39(8):803–807]
AARC Clinical Practice Guideline
Delivery of Aerosols to the Upper Airway
AUA 1.0 PROCEDURE:
Administration of aerosols to the upper airway
AUA 2.0 DESCRIPTION:
Delivery of therapeutic aerosols to the upper airway including the nose, pharynx, and larynx--therapeutic aerosols are indicated for upper airway inflammation, anesthesia, rhinitis, and administration of medications for systemic effect.
Devices for upper airway delivery include metered dose inhalers (MDI), metered spray pumps (MSP), hand-bulb atomizers (HBA), and small-volume (SVN), large-volume (LVN), and ultrasonic nebulizers (USN).
Nasopharyngeal deposition is greatest for particles in the range of 5-20 microns.(1)
AUA 3.0 SETTING:
Bland or pharmacologically active aerosol therapy can be administered in a number of settings, including hospital, clinic, diagnostic laboratory, extended care facility, and home.
AUA 4.0 INDICATIONS:
- 4.1 Upper airway inflammation (eg, to relieve inflammation due to laryngotracheobronchitis(2))
- 4.2 Anesthesia (eg, to control pain and gagging during endoscopic procedures(3-7))
- 4.3 Rhinitis (eg, to relieve inflammation and vascular congestion(8,9))
- 4.4 Systemic disease (eg, to deliver peptides such as insulin(10))
AUA 5.0 CONTRAINDICATIONS:
Known hypersensitivity to the medication being delivered
AUA 6.0 HAZARDS/COMPLICATIONS:
- 6.1 Administration of medications for upper airway inflammation may result in
- 6.1.1 bronchospasm,(11,12)
- 6.1.2 rebound of symptoms,
- 6.1.3 systemic side effects.
- 6.2 Administration of medications for anesthesia(3-7) may result in
- 6.2.1 inhibition of gag reflex,
- 6.2.2 choking,
- 6.2.3 dehydration of epithelium,
- 6.2.4 allergic reactions,
- 6.2.5 excessive systemic effect,
- 6.2.6 bronchospasm,
- 6.2.7 nosocomial infection from contaminated delivery device or medication (See AARC CPG on Selection of Aerosol Delivery Device(13)).(14)
- 6.3 Administration of medications for rhinitis(15-21) may result in
- 6.3.1 nasal rebound (including rhinitis medicamentosa) after extended use of alpha adrenergic decongestants;
- 6.3.2 delayed effect (eg, effects of steroids are not immediate);
- 6.3.3 sensation of irritation and burning in the nose;
- 6.3.4 sneezing attacks (immediately following administration);
- 6.3.5 mucosal ulceration and bleeding;
- 6.3.6 postnasal drip.
- 6.4 Systemic disease--medication may cause nasal irritation or toxic effects.(9,10)
AUA 7.0 LIMITATIONS OF PROCEDURE:
- 7.1 Upper airway inflammation--patient cooperation is not essential but may be desirable for effective administration in some applications.
- 7.2 Anesthesia--direct local application of anesthetic agents may require direct visualization.
- 7.3 Rhinitis
- 7.3.1 In the presence of excessive nasal mucus secretion or edema of the nasal mucosa, the drug may fail to reach the site of intended action. Deposition may be compromised by the presence of nasal polyps or a deviated septum.
- 7.3.2 Response may not be readily observable for drugs such as cromolyn sodium and steroids.
- 7.4 Systemic disease
- 7.4.1 In the presence of excessive nasal mucus secretion or edema of the nasal mucosa, the drug may fail to reach the site of intended action. Deposition may also be compromised by the presence of nasal polyps or a deviated septum.
- 7.4.2 Response may not be immediately apparent.
AUA 8.0 ASSESSMENT OF NEED:
The presence of one or more of the following may suggest the need for aerosol application.
- 8.1 In upper airway inflammation--
- 8.1.1 stridor
- 8.1.2 brassy croup-like cough
- 8.1.3 hoarseness following extubation
- 8.1.4. diagnosis of laryngeotracheobronchitis or croup
- 8.1.5 recent extubation
- 8.1.6 evidence of inflamed upper airway
- 8.1.7 soft-tissue radiograph suggesting edema
- 8.1.8 increased work of breathing
- 8.2 For anesthesia--
- 8.2.1 severe localized pain in upper airway
- 8.2.2 impending invasive instrumentation of the upper airway
- 8.3 In rhinitis--
- 8.3.1 diagnosis of allergic, non-allergic, or infectious rhinitis
- 8.3.2 symptomatic need:
- 18.104.22.168 nasal congestion
- 22.214.171.124 rhinorrhea
- 126.96.36.199 sneezing
- 188.8.131.52 itching of nose, eyes, or palate
- 8.4 In systemic disease--presence of a systemic disease that warrants intranasal delivery of a therapeutic agent
AUA 9.0 ASSESSMENT OF OUTCOME:
- 9.1 In upper airway inflammation, effectiveness of administration may be indicated by
- 9.1.1 reduced stridor,
- 9.1.2 reduced hoarseness,
- 9.1.3 improvement in soft-tissue radiograph,
- 9.1.4 decreased work of breathing, as evidenced by decreased use of accessory muscles.
- 9.2 For anesthesia, effectiveness of administration is marked by reduced discomfort in the patient.
- 9.3 In rhinitis, effectiveness of administration may be indicated by
- 9.3.1 reduced nasal congestion,
- 9.3.2 improved airflow through nose,
- 9.3.3 reduced rhinorrhea,
- 9.3.4 reduced sneezing,
- 9.3.5 reduced itching of nose, eyes, or palate.
- 9.4 Systemic disease--effectiveness of administration of agent is marked by the presence of the appropriate systemic therapeutic response.
AUA 10.0 RESOURCES:
- 10.1 Equipment:
- 10.1.1 metered dose inhaler, or MDI, with nasal adapter
- 10.1.2 metered spray pump, or MSP
- 10.1.3 hand-bulb atomizer, or HBA
- 10.1.4 small volume nebulizer, or SVN, (use requires gas source, flowmeter, connecting tubing, and mask or mouthpiece)
- 10.1.5 large volume nebulizer, or LVN, (use requires gas source, flowmeter, large-bore tubing, and mask or mouthpiece)
- 10.1.6 ultrasonic nebulizer, or USN, (use requires electrical source, large- bore tubing and mouthpiece, mask, or nasal adapter)
- 10.2 Personnel:
- 10.2.1 A Level I caregiver may be the provider of service after Level II personnel have established need for a specific device by patient assessment, initial administration(s) has been completed, and patient is considered stable. Level I personnel (typically CRTT or RRT) must demonstrate appropriate technique for
- 10.2.1.1 preparing and measuring medications;
- 10.2.1.2 administering medication;
- 10.2.1.3 equipment use;
- 10.2.1.4 cleaning equipment;
- 10.2.1.5 disposal of wastes;
- 10.2.1.6 encouraging effective breathing patterns;
- 10.2.1.7 modifying treatment in response to adverse reactions as instructed, with appropriate communication with physician and Level II caregiver, in response to severity of symptoms;
- 10.2.1.8 Universal Precautions and proper infection control
- 10.2.2 Level II personnel should perform initial assessments of all patients and care for the unstable patient. The Level II caregiver should be an RRT or have equivalent training in patient assessment, aerosol administration, pulmonary function, and lung mechanics and should have demonstrated his/her knowledge and ability to perform related to the following:
- 10.2.2.1 indications and limitations for MDI, MSP, MBA, SVN, LVN, and USN;
- 10.2.2.2 proper use, maintenance, and cleaning of equipment, including filter and scavenging systems;
- 10.2.2.3 risks inherent in the medications and specific devices;
- 10.2.2.4 procedures for safely disposing of medical wastes;
- 10.2.2.5 breathing patterns and coughing techniques;
- 10.2.2.6 technique modification in response to adverse reactions;
- 10.2.2.7 dose and/or frequency modification in response to severity of symptoms, as prescribed;
- 10.2.2.8 assessment of patient condition and response to therapy;
- 10.2.2.9 auscultation, inspection, and vital-signs determination;
- 10.2.2.10 measurement of peak expiratory flowrate, flow-volumes, timed volumes, and ventilatory mechanics;
- 10.2.2.11 recognition and response to adverse reactions to and complications of medication and/or procedure;
- 10.2.2.12 instructing patients and families.
AUA 11.0 MONITORING:
The extent of patient monitoring should be determined on the basis of the stability and severity of the patient's condition:
- 11.1 patient compliance and increase or decrease in symptoms, signs, and patient subjective response as specified in Section 8;
- 11.2 heart rate and rhythm, blood pressure;
- 11.3 change in indicators of therapeutic effect (eg, blood-glucose level with insulin).
AUA 12.0 FREQUENCY:
Frequency of administration is specific for purpose of administration and medication used.
AUA 13.0 INFECTION CONTROL:
Aerosol Therapy Guidelines Committee:
- 13.1 Universal Precautions for body fluid isolation are to be implemented.(22)
- 13.2 Centers for Disease Control and Prevention recommendations for control of exposure to tuberculosis and droplet nuclei are to be implemented when patient is known to have tuberculosis or has other risk factors for the disease.(23)
- 13.2.1 To reduce aerosol contamination of room air,
- 184.108.40.206 enclose and contain aerosol administration;
- 220.127.116.11 filter aerosols that bypass or are exhaled by patient;
- 13.2.2 When aerosol release to the atmosphere cannot be routed through a filter,
- 18.104.22.168 use filtered scavenger systems to remove aerosols that cannot be contained;
- 22.214.171.124 provide local exhaust ventilation to remove aerosols that are released into room air;
- 126.96.36.199 provide frequent air exchange to dilute concentration of aerosol in room;
- 188.8.131.52 allow exchange of gas in the room to eliminate 99% of aerosol before next patient enters or receives treatment in that area.
- 13.2.3 It remains unclear whether high efficiency particulate air (HEPA) filters completely remove infectious particles from the air.
- 13.2.4 Filters, nebulizers, and other contaminated disposable components of the aerosol delivery system should be treated as medical waste. Applicator nozzles for multidose atomizers should be changed between patients.
- 13.2.5 Personal protection devices should be used to reduce exposure when engineering alternatives are not adequate or in place.(23)
- 184.108.40.206 Use properly fitted respirator with adequate filtration when flow exhaust cannot control removal of aerosols.
- 220.127.116.11 Goggles, gloves, masks, and gowns should be used to serve as splatter shields and to reduce exposure to body substances.
- 13.2.6 Personnel should safely dispose of hazardous wastes.
- 13.2.7 Personnel who are at high risk for adverse effects from exposure should be offered an opportunity for alternative assignments.
- 13.3 Nebulizers should not be reused between patients without disinfection.
- 13.4 Nebulizers should be changed or sterilized
- 13.4.1 at conclusion of a procedure that is not to be repeated;
- 13.4.2 every 24 hours with repeated or continuous administration or more often when visibly soiled;
- 13.5 Nebulizers should not be rinsed with tap water between treatments.(24,25)
- 13.6 Solutions should be handled aseptically.
- 13.7 Diluent solutions from multidose vials (eg, distilled water and normal saline) must be handled aseptically and should be discarded after 24 hours.
Jon Nilsestuen PhD RRT, Chairman, Houston TX
James B Fink MBA RRT, Chicago IL
James K Stoller MD, Cleveland OH
James Volpe RRT, San Diego CA
Theodore Witek Jr DrPH RPFT RRT, Ridgefield CT
- Covert DS, Frank R. Atmospheric particles: behavior and functional effects. In: Nadel JA. Physiology and pharmacology of the airways. New York: Marcel Decker Inc, 1980:259.
- Skolnik NS. Treatment of croup: a critical review. Am J Dis Child 1989;143(9):1045-1049.
- Perry LB. Topical anesthesia for bronchoscopy. Chest 1978;73(5, Suppl):691-693.
- Fry WA. Techniques of topical anesthesia for bronchoscopy. Chest 1978;73(5, Suppl):694-696.
- McAlpine LG, Thomson NC. Lidocaine-induced bronchoconstriction in asthmatic patients: relation to histamine airway responsiveness and effect of preservative. Chest 1989;96(5):1012-1015.
- Kirkpatrick MB. Lidocaine topical anesthesia for flexible bronchoscopy (editorial). Chest 1989;96(5):965-967.
- Berger R, McConnell JW, Phillips B, Overman TL. Safety and efficacy of using high-dose topical and nebulized anesthesia to obtain endobronchial cultures. Chest 1989;95(2):299-303.
- Naclerio RM. Allergic rhinitis. N Engl J Med 1991;325(12):860-869.
- Witek TJ, Schachter EN. Pharmacology and therapeutics in respiratory care. Philadelphia: WB Saunders Co, 1994:49-50.
- Pontiroli AE, Calderara A, Pozza G. Intranasal drug delivery: potential advantages and limitations from a clinical pharmacokinetic perspective. Clin Pharmacokinet 1989;17(5):299-307.
- Schoeffel RE, Anderson SD, Altounyan RE. Bronchial hyperreactivity in response to inhalation of ultrasonically nebulised solutions of distilled water and saline. Br Med J Clin Res Ed 1981;283(6302):1285-1287.
- Eschenbacher WL, Boushey HA, Sheppard D. Alteration in osmolarity of inhaled aerosols causes bronchoconstriction and cough, but absence of a permeant anion causes cough alone. Am Rev Respir Dis 1984;129(2): 211-215.
- Sanders CV Jr, Luby JP, Johanson WG Jr, Barnett JA, Sanford JP. Serratia marcescens infections from inhalation therapy medications: nosocomial outbreak. Ann Intern Med 1970;73(1):15-21.
- Williams OA, Wilcox MH, Nicol CD, Spencer RC, Reilly CS. Lignocaine spray applicators are a potential source of cross-infection in the anaesthetic room. Anaesthesia 1993;48(1):61-62.
- Toohill RJ, Lehman RH, Grossman TW, Belson TP. Rhinitis medicamentosa. Laryngoscope 1981;91(10): 1614-1621.
- Mabry RL. Rhinitis medicamentosa: the forgotten factor in nasal obstruction. South Med J 1982;75(7):817-819.
- Capel LH, Swanston AR. Beware congesting nasal decongestants (editorial). Br Med J Clin Res Ed 1986;293 (6557):1258-1259.
- Walker JS. Rhinitis medicamentosa. J Allergy 1952;23: 183-186.
- Osguthorpe JD, Shirley R. Neonatal respiratory distress from rhinitis medicamentosa. Laryngoscope 1987;97(7, Part 1): 829-831.
- Blue JA. Rhinitis medicamentosa. Ann Allergy 1968;26 (8):425-429.
- Black MJ, Remsen KA. Rhinitis medicamentosa. Can Med Assoc J 19808;122(4):881-884.
- Centers for Disease Control. Update: Universal Precautions for prevention and transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR 1988;37(24):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.
- Brady MT. Nosocomial legionnaires' disease in a children's hospital. J Pediatr 1989;115(1):46-50.
- Mastro TD, Fields BS, Breiman RF, Campbell J, Plikaytis BD, Spika JS. Nosocomial Legionnaires' disease and use of medication nebulizers. J Infect Dis 1991;163(3):667-671.
Interested persons may copy these Guidelines for noncommercial
purposes of scientific or educational advancement. Please credit AARC and Respiratory
Reprinted from the August 1994 issue of RESPIRATORY CARE [Respir Care 1994; 39(8):803–807]