Nebulizer Nebulizer Therapy in Therapy in

Spontaneous Spontaneous Breathing Breathing Patients PIPatients PI

Leonor Ortiz, RRTLeonor Ortiz, RRT Ricardo Montoya, Ricardo Montoya, RRT, AE-CRRT, AE-C

Nebulizer TherapyNebulizer Therapy

Breathing treatmentsBreathing treatments Medication delivery to the Medication delivery to the

lungs.lungs. Improve breathing.Improve breathing. Small airways Small airways

bronchodilatation.bronchodilatation. Promote airway hygiene.Promote airway hygiene.

Nebulizer TherapyNebulizer TherapyWhere does the inhaled aerosol go?Where does the inhaled aerosol go?

Performance Performance ImprovementImprovement

Mask vs mouthpiece?Mask vs mouthpiece?

Goals:Goals: To assess utilization of proper treatment To assess utilization of proper treatment

techniques.techniques. To evaluate the impact of patient and RT To evaluate the impact of patient and RT

education on the use of nebulizers and education on the use of nebulizers and therapy via mouthpiece.therapy via mouthpiece.

To evaluate the maintenance of the To evaluate the maintenance of the nebulizer.nebulizer.

Evidence Based Evidence Based Literature SearchLiterature Search

National Asthma Expert Panel Report 2007 National Asthma Expert Panel Report 2007 updateupdate

AARC- RT Aerosol Therapy Delivery GuideAARC- RT Aerosol Therapy Delivery Guide AARC 2012 Nebulized Therapy CPG updateAARC 2012 Nebulized Therapy CPG update Infection Control in Cystic Fibrosis: Cohorting, Infection Control in Cystic Fibrosis: Cohorting,

Cross- Contamination and the RT. Cross- Contamination and the RT. Guidelines for Preventing Health-Care-Guidelines for Preventing Health-Care-

Associated Pneumonia, 2003 Associated Pneumonia, 2003

AARC-Aerosol Delivery Devices in the AARC-Aerosol Delivery Devices in the Treatment of Asthma.Treatment of Asthma.

Evidence Based Evidence Based GuidelinesGuidelines

All coherent patients All coherent patients >> 3 yrs -use 3 yrs -use mouthpiece.mouthpiece.

Educate patient on optimal breathing Educate patient on optimal breathing technique.technique.

Rinse the nebulizer with sterile water Rinse the nebulizer with sterile water after the treatment.after the treatment.

Air dry the nebulizer after the rinse.Air dry the nebulizer after the rinse.

Current Practice Current Practice Based EvaluationBased Evaluation

Done in 2 ways:Done in 2 ways:Patient surveys and observationPatient surveys and observation

Survey questions:Survey questions: Were you educated on how to breathe Were you educated on how to breathe

during the treatment?during the treatment?

Were you encouraged to hold your breath Were you encouraged to hold your breath during your treatment?during your treatment?

Was your treatment given via mask or Was your treatment given via mask or mouthpiece?mouthpiece?

Current PracticeCurrent PracticeBased EvaluationBased Evaluation

Observations:Observations:

Nebulizer setup (mask vs. mouthpiece)Nebulizer setup (mask vs. mouthpiece)

Residual solution found in nebulizerResidual solution found in nebulizer

Water bottle available for nebulizer Water bottle available for nebulizer rinserinse

Data Collection Data Collection PeriodsPeriods

Current practice March- Current practice March- May 2012May 2012

New practice July- New practice July- September 2012September 2012

RT In-serviceRT In-serviceAll RT personnel were in-serviced.All RT personnel were in-serviced.

Data collection for Mar - May reviewed.Data collection for Mar - May reviewed.

Evidence based guidelines reviewedEvidence based guidelines reviewed..

Performance Improvement Performance Improvement Expectation.Expectation.

Data Collection Data Collection ResultsResults

050

100150200250300350400

Mar April May July Aug. Sept.

Mouthpiece treatments Mask treatments

Number of treatments

Data Collection Data Collection ResultsResults

0

5

10

15

20

25

Mar April May July Aug. Sept.

Residual solution Water for rinse

Number of observations

Data Collection Data Collection ResultsResults

0

2

4

6

8

10

12

Mar April May July Aug. Sept.

Breathing education Breath hold

Number of surveys

Optimal Breathing Pattern Optimal Breathing Pattern EducationEducation

Optimal breathing technique: Optimal breathing technique:

Sit patient in upright position whenever possible.Sit patient in upright position whenever possible. Nebulizer should be upright.Nebulizer should be upright. Breathe normally with occasional deep breaths Breathe normally with occasional deep breaths

followed by a breath hold. followed by a breath hold.

* Instruct on 4-5 normal breaths then a deep * Instruct on 4-5 normal breaths then a deep breath with a couple sec. breath hold and breath with a couple sec. breath hold and repeat. repeat.

* Regardless of whether the treatment is given * Regardless of whether the treatment is given via mouthpiece or mask the patient must be via mouthpiece or mask the patient must be instructed to breath through the mouth.instructed to breath through the mouth.

Nebulizer MaintenanceNebulizer Maintenance

SVN Nebulizer maintenance: SVN Nebulizer maintenance: Empty any residual solution.Empty any residual solution. Rinse with sterile water. Rinse with sterile water. Place the nebulizer, mouthpiece, OPlace the nebulizer, mouthpiece, O22 tubing tubing

and corrugated tubing over the paper towel in and corrugated tubing over the paper towel in the patient box. the patient box.

Place all other nebulizer therapy items in the Place all other nebulizer therapy items in the box. box.

* All patients receiving SVN therapy will have a * All patients receiving SVN therapy will have a (cake) box to use as nebulizer storage. (cake) box to use as nebulizer storage.

Clinical Practice Guidelines Clinical Practice Guidelines UpdateUpdate

Nebulizer storage box:Nebulizer storage box: The box will be provided at designated locations.The box will be provided at designated locations. Label box with patient name, date and RT Label box with patient name, date and RT

initials. initials. Line the inside-base of box with paper towels.Line the inside-base of box with paper towels. Change the box Q48hrs and PRN. Change the box Q48hrs and PRN. Patient may take the box and contents home. Patient may take the box and contents home. If the box is to be disposed of, the name must be If the box is to be disposed of, the name must be

removed. removed.

QuestionsQuestions