A Protocol to assess and Administer Aerosol Bronchodilator Therapy

We have developed an aerosol bronchodilator assessment protocol to provide patients with the most appropriate method of aerosol bronchodilator delivery and to discontinue therapy if it is no longer warranted. Using this medical-staff-approved protocol, respiratory therapists may deliver the bronchodilator via the nebulizer of an IPPB device, a hand-held pneumatically powered small-volume nebulizer, or a metered-dose inhaler (MDI). IPPB is used in obtunded patients and in patients who have a vital capacity (VC) less than 30% of their predicted value. An MDI is used if the patient can demonstrate acceptable technique with the device; a reservoir aerosol delivery system (RADS) can be added for patients who have difficulty coordinating the use of the MDI. MDI users who demonstrate acceptable technique without coaching and who are receiving no other respiratory therapy can self-administer their treatments with nursing supervision. A pneumatically powered small-volume nebulizer is used when the patient cannot use the MDI correctly and IPPB is not appropriate. The effectiveness of aerosol bronchodilator therapy is evaluated using pulse rate, peak expiratory flowrate (PEFR), VC, breath sounds, and sputum production; the respiratory therapist discontinues aerosol bronchodilator therapy if the patient's pulse rate increases more than 30% or if the patient's sputum production, PEFR, VC, and breath sounds are unchanged. Although this protocol allows the respiratory therapist to determine the technique for administration of the aerosol bronchodilator and to discontinue therapy that is no longer indicated, the therapist cannot alter the specific medication, the medication dose, or the frequency of administration without a specific physician order. We have found that this protocol determines the most appropriate means of aerosol bronchodilator administration and provides objective evaluation of the therapy, thus identifying unnecessary aerosol bronchodilator therapy.