Reprinted from the August 1992 issue of RESPIRATORY CARE [Respir Care 1992;37(8):891–897]
AARC Clinical Practice Guideline
Selection of Aerosol Delivery Device
AD 1.0 PROCEDURE:
Selection of a device for delivery of aerosol to the lower airways
AD 2.0 DESCRIPTION:
The selection of a device for administration of pharmacologically active aerosol to the lower airway. The device selected should produce particles with a mass median aerodynamic diameter (MMAD) of 2-5 microns.(1,2)
These devices include
Metered dose inhalers (MDI)
MDIs with accessory device (eg, spacer)
Dry powder inhalers (DPI)
Small volume nebulizers (SVN)
Large volume nebulizers (LVN)
Ultrasonic nebulizers (USN)
This guideline does not address bland aerosol administration and sputum induction.
AD 3.0 SETTING:
Aerosol therapy can be administered in a number of settings including hospital, clinic, extended care facility, and home.
AD 4.0 INDICATIONS:
The need to deliver--as an aerosol to the lower airways--a medication from one of the following drug classifications:
Beta adrenergic agents
Anticholinergic agents (antimuscarinics)
Anti-inflammatory agents (eg, corticosteroids)
Mediator-modifying compounds (eg, cromolyn sodium)
The selection of a device for delivery of aerosol for parenchymal deposition (eg, antibiotics) will be addressed in another Guideline.
AD 5.0 CONTRAINDICATIONS:
- 5.1 No contraindications exist to the administration of aerosols by inhalation.
- 5.2 Contraindications related to the substances being delivered may exist. Consult the package insert for product-specific contraindications.
AD 6.0 HAZARDS/COMPLICATIONS:
- 6.1 Malfunction of device(3-5) and/or improper technique(6-12) may result in underdosing.
- 6.2 The potential exists for malfunction of device and/or improper technique (inappropriate patient use) to result in overdosing.
- 6.3 Complications of specific pharmacologic agent may occur.
- 6.4 Cardiotoxic effects of Freon have been reported as an idiosyncratic response that may be a problem with excessive use of MDI.(13-18)
- 6.5 Freon may affect the environment by its effect on the ozone layer.(19-21)
- 6.6 Repeated exposure to aerosols has been reported to produce asthmatic symptoms in some caregivers.(22)
AD 7.0 LIMITATIONS OF PROCEDURE OR DEVICE:
- 7.1 Only a small percent of output deposits in the airway (< or = 10%).23-27
- 7.2 Efficacy of the device is technique dependent (eg, coordination, breathing pattern, inspiratory hold).(6-9,28-32) The reader is referred to Kacmarek RM, Hess D. The interface between patient and aerosol generator. Respir Care 1991;36:952-976 for detailed descriptions of optimal technique.
- 7.3 Efficacy of the device is design dependent (ie, output and particle size).(4,5,33)
- 7.4 Reduced deposition of aerosol to the lower airways is associated with the following and may require consideration of increased dose:
- 7.4.1 mechanical ventilation;(26,27,34-36)
- 7.4.2 artificial airways;(34-39)
- 7.4.3 airway caliber (eg, infants and children);(22,37-39)
- 7.4.4 severity of obstruction.(40-42)
- 7.5 Patient compliance(12)
- 7.6 Limitations of specific devices
- 7.6.1 Metered Dose Inhaler:
- 18.104.22.168 Environmental concerns(CFC)(20,21)
- 22.214.171.124 Inadequate technique(6-8,28-32,43)
- 126.96.36.199 Inadequate instruction(9-12)
- 7.6.2 MDI accessory device (spacer or holding chamber):
- 188.8.131.52 Adds to cost over MDI alone
- 184.108.40.206 More bulky than MDI alone
- 7.6.3 Dry powder inhaler:
- 220.127.116.11 At the present time, patients must load each dose for most medica-tions.
- 18.104.22.168 Reduced inspiratory flow (< 60 L/min) can lead to reduced deposition.(44-46)
- 22.214.171.124 Irritation to airway(33)
- 126.96.36.199 Humidity may cause clumping of particles.
- 7.6.4 Small Volume Nebulizer:
- 188.8.131.52 Time- and labor-intensive
- 184.108.40.206 Less portable
- 220.127.116.11 Requires compressed-gas source or electricity
- 18.104.22.168 Vulnerable to contamination(47-50)
- 22.214.171.124 Lack of convenience may affect patient compliance
- 7.6.5 Large Volume Nebulizer:
- 126.96.36.199 Limited to acute and critical care setting
- 188.8.131.52 Requires close monitoring
- 184.108.40.206 Time- and cost-intensive
- 220.127.116.11 Vulnerable to contamination(46-49)
- 18.104.22.168 Reconcentration of solution may occur over long period of time due to evaporation by dry gas.
- 7.6.6 Ultrasonic Nebulizer:
- 22.214.171.124 Cost of device
- 126.96.36.199 Mechanical reliability
- 188.8.131.52 Requires electrical power source
- 184.108.40.206 Vulnerable to contamination
AD 8.0 ASSESSMENT OF NEED:
- 8.1 Based on proven therapeutic efficacy,(25,51-60) variety of available medications, and cost-effectiveness(51,61-64) the MDI with accessory device should be the first method to consider for administration of aerosol to the airway.
- 8.2 Lack of availability of prescribed drug in MDI, dry powder, or solution form.
- 8.3 Inability of the patient to use device properly with coaching and instruction should lead to consideration of other devices.
- 8.4 Patient preference for a given device that meets therapeutic objectives should be honored.
- 8.5 When there is need for large doses, MDI, SVN, or LVN may be used. Clear superiority of any one method has not been established. Convenience and patient tolerance of procedure should be considered.
- 8.6 When spontaneous ventilation is inadequate (eg, as in kyphoscoliosis or neuromuscular disorders, exacerbation of severe bronchospasm with impending respiratory failure that does not respond to other forms of therapy), delivery by a positive pressure breathing device (IPPB) should be considered.(65-67)
AD 9.0 ASSESSMENT OF OUTCOME:
- 9.1 Proper technique applying device
- 9.2 Patient response to or compliance with procedure
- 9.3 Objectively measured improvement (eg, increased FEV1 or peak flow)
AD 10.0 RESOURCES:
- 10.1 Equipment:
- 10.1.1 MDI-canister with actuator supplied by manufacturer; MDI accessory device that properly fits MDI mouthpiece or mask; adapters for specific circumstances (eg, tracheostomy)
- 10.1.2 Small volume nebulizer--gas source, tubing, flowmeter, and mouthpiece or mask
- 10.1.3 Large volume nebulizer--gas source, flowmeter, connecting tubing, and mouthpiece or mask
- 10.1.4 Mechanical ventilator--SVN or MDI, adapter in inspiratory line of circuit
- 10.1.5 IPPB machine (ie, pressure-limited ventilator)-nebulizer, gas source, connecting tubing, and mouthpiece or mask
- 10.1.6 Manual resuscitator--for 'bagging in' aerosol from MDI or SVN
- 10.2 Personnel:
- 10.2.1 Knowledge and skills at several levels are required to fully utilize and apply these devices.
- 10.2.1.1 Level II personnel provide initial assessments and care of the unstable patient:
- 10.2.1.1.1 utilizing proper technique for administration of MDI, accessory device, dry powder inhaler, SVN, LVN, USN; and SVN via IPPB;
- 10.2.1.1.2 practicing proper use, maintenance, and cleaning of equipment;
- 10.2.1.1.3 encouraging effective breathing patterns and coughing techniques;
- 10.2.1.1.4 modifying technique in response to adverse reactions;
- 10.2.1.1.5 modifying dosages and/or frequency as prescribed in re-sponse to severity of symptoms;
- 10.2.1.1.6 assessing patient condition and response to therapy;
- 10.2.1.1.7 performing auscultation and inspection and taking vital signs;
- 10.2.1.1.8 performing peak expiratory flowrate, spirometry, or ventilatory mechanics;
- 10.2.1.1.9 recognizing and res-ponding to therapeutic and adverse responses and complications of medication and/or procedure;
- 10.2.1.1.10 understanding and complying with Universal Precautions.
- 10.2.1.2 The patient, family, or home caregiver; Level-I hospital personnel provide routine care of the patient:
- 10.2.1.2.1 preparing, measuring, and mixing medication;
- 10.2.1.2.2 demonstrating proper technique for administration of medication;
- 10.2.1.2.3 using equipment properly;
- 10.2.1.2.4 cleaning equipment;
- 10.2.1.2.5 encouraging effective breathing patterns and coughing techniques;
- 10.2.1.2.6 modifying technique in response to adverse reactions as instructed, with appropriate communication with physician or Level-II care provider;
- 10.2.1.2.7 modifying dosages and/or frequency as prescribed, with appropriate communication with physician, in response to severity of symptoms;
- 10.2.1.2.8 using the peak flowmeter properly and documenting results.
AD 11.0 MONITORING:
- 11.1 Performance of the device
- 11.2 Technique of device application
- 11.3 Assessment of patient response including changes in vital signs
AD 12.0 FREQUENCY:
12.1 Initiation of therapy after careful assessment of need (as outlined above)
12.2 The change from one type of device to another is based on a change in patient's condition or ability to use the specific device.
AD 13.0 INFECTION CONTROL:
Aerosol Guidelines Committee:
- 13.1 Universal Precautions must be exercised for body substance isolation.(67)
- 13.2 SVN and LVN are for single patient use or should be subjected to high-level disinfection between patients.
- 13.3 Published data establishing a safe use-period for SVN and LVN are lacking; however they probably should be changed or subjected to high-level disinfection at approximately 24-hour intervals.
- 13.4 Medications:
- 13.4.1 Medications should be handled aseptically.
- 13.4.2 Tap water should not be used as the diluent.(69)
- 13.4.3 Medications from multidose sources in acute care facilities must be handled aseptically and discarded after 24 hours, unless manufacturer's recommendations specifically state that medications may be stored longer than 24 hours.
- 13.5 MDI accessory devices are for single patient use only. Cleaning of accessory devices is based on aesthetic criteria.
- 13.6 There are no documented concerns with contamination of medication in MDI canisters.
Jon Nilsestuen PhD RRT, Chairman, Houston TX
Jim Fink MBA RRT, San Francisco CA
Theodore Witek Jr DrPH RPFT RRT, Ridgefield CT
James Volpe III MEd RRT, San Diego CA
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Interested persons may copy these Guidelines for noncommercial
purposes of scientific or educational advancement. Please credit AARC and Respiratory
Reprinted from the August 1992 issue of RESPIRATORY CARE [Respir Care 1992;37(8):891–897]