Nebulizer Therapy in Spontaneous Breathing Patients PI Leonor Ortiz, RRT Ricardo Montoya, RRT, AE-C Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013

1. Nebulizer Therapy inNebulizer Therapy in
Spontaneous BreathingSpontaneous Breathing
Patients PIPatients PI
Leonor Ortiz, RRTLeonor Ortiz, RRT
Ricardo Montoya, RRT, AE-CRicardo Montoya, RRT, AE-C

2. Nebulizer TherapyNebulizer Therapy
Breathing treatmentsBreathing treatments
 Medication delivery to the lungs.Medication delivery to the lungs.
 Improve breathing.Improve breathing.
 Small airways bronchodilatation.Small airways bronchodilatation.
 Promote airway hygiene.Promote airway hygiene.

3. Nebulizer TherapyNebulizer Therapy
Where does the inhaled aerosol go?Where does the inhaled aerosol go?

4. Performance ImprovementPerformance Improvement
Mask vs mouthpiece?Mask vs mouthpiece?
Goals:Goals:
 To assess utilization of proper treatmentTo assess utilization of proper treatment
techniques.techniques.
 To evaluate the impact of patient and RTTo evaluate the impact of patient and RT
education on the use of nebulizers and therapyeducation on the use of nebulizers and therapy
via mouthpiece.via mouthpiece.
 To evaluate the maintenance of the nebulizer.To evaluate the maintenance of the nebulizer.

5. Evidence BasedEvidence Based
Literature SearchLiterature Search
 National Asthma Expert Panel Report 2007 updateNational Asthma Expert Panel Report 2007 update
 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-AssociatedGuidelines for Preventing Health-Care-Associated
Pneumonia, 2003Pneumonia, 2003
 AARC-Aerosol Delivery Devices in the Treatment ofAARC-Aerosol Delivery Devices in the Treatment of
Asthma.Asthma.

6. Evidence Based GuidelinesEvidence Based Guidelines
 All coherent patientsAll coherent patients >> 3 yrs -use mouthpiece.3 yrs -use mouthpiece.
 Educate patient on optimal breathingEducate patient on optimal breathing
technique.technique.
 Rinse the nebulizer with sterile water afterRinse the nebulizer with sterile water after
the treatment.the treatment.
 Air dry the nebulizer after the rinse.Air dry the nebulizer after the rinse.

7. Current PracticeCurrent 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 during theWere you educated on how to breathe during the
treatment?treatment?
 Were you encouraged to hold your breath duringWere you encouraged to hold your breath during
your treatment?your treatment?
 Was your treatment given via mask or mouthpiece?Was your treatment given via mask or mouthpiece?

8. Current PracticeCurrent Practice
Based 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 rinseWater bottle available for nebulizer rinse

9. Data Collection PeriodsData Collection Periods
Current practice March- May 2012Current practice March- May 2012
New practice July- September 2012New practice July- September 2012

10. RT In-serviceRT In-service
All 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 Expectation.Performance Improvement Expectation.

11. Data Collection ResultsData Collection Results
0
50
100
150
200
250
300
350
400
Mar April May July Aug. Sept.
Mouthpiece treatments Mask treatments
Number of
treatments

12. Data Collection ResultsData Collection Results
0
5
10
15
20
25
Mar April May July Aug. Sept.
Residual solution Water for rinse
Number of
observations

13. Data Collection ResultsData Collection Results
0
2
4
6
8
10
12
Mar April May July Aug. Sept.
Breathing education Breath hold
Number
of surveys

14. Optimal Breathing Pattern EducationOptimal Breathing Pattern Education
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 breathsBreathe normally with occasional deep breaths
followed by a breath hold.followed by a breath hold.
* Instruct on 4-5 normal breaths then a deep breath* Instruct on 4-5 normal breaths then a deep breath
with a couple sec. breath hold and repeat.with a couple sec. breath hold and repeat.
* Regardless of whether the treatment is given via* Regardless of whether the treatment is given via
mouthpiece or mask the patient must be instructedmouthpiece or mask the patient must be instructed
to breath through the mouth.to breath through the mouth.

15. 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 andtubing and
corrugated tubing over the paper towel in the patientcorrugated tubing over the paper towel in the patient
box.box.
 Place all other nebulizer therapy items in the box.Place all other nebulizer therapy items in the box.
* All patients receiving SVN therapy will have a (cake)* All patients receiving SVN therapy will have a (cake)
box to use as nebulizer storage.box to use as nebulizer storage.

16. Clinical Practice Guidelines UpdateClinical Practice Guidelines Update
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 initials.Label box with patient name, date and RT 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 beIf the box is to be disposed of, the name must be
removed.removed.

17. QuestionsQuestions