Respiratory Care and Aerosol Therapy Kopp Overview

AARC and Clinical Practice Guidelines

  • The American Association of Respiratory Care (AARC) is the national organization that establishes clinical practice guidelines.

    • These guidelines cover various respiratory care procedures.

    • The aerosol delivery guideline consists of 171 pages, serving as a comprehensive reference.

Terminology and Organizations

  • CDC (Centers for Disease Control):

    • National organization monitoring disease outbreaks.

    • Based in Atlanta, Georgia, near Emory University Hospital, a top-rated facility.

  • Cystic Fibrosis (CF):

    • A genetic disorder affecting the lungs, leading to severe respiratory issues.

  • DPI (Dry Powder Inhaler):

    • Inhalers that deliver medication in powdered form via a capsule.

    • Example: Spiriva, used primarily at home for COPD management.

Medications and Mechanisms

  • Spiriva:

    • An anticholinergic medication blocking acetylcholine and parasympathetic activation, which causes bronchoconstriction.

    • Not considered a first-line rescue drug but often used in combination with beta-2 adrenergics.

  • FDA (Food and Drug Administration):

    • Responsible for approving medication formulations, such as Hydrofluorocarbons (HFA).

    • HFA replaced CFCs which were harmful to the ozone layer.

  • Mean Median Aerodynamic Diameter (MMAD):

    • Particle size relevant for aerosol delivery.

    • Optimal size for reaching lower airways: between 1 and 5 microns.

Types of Inhalers and Delivery Devices

  • Pressurized Metered Dose Inhaler (pMDI):

    • Typical albuterol inhaler using pressurized propellant to deliver medication.

  • SPAG (Small Particle Aerosol Generator):

    • Historical device used for delivering ribavirin, an antiviral for RSV in infants.

  • Small Volume Nebulizer (SVN):

    • Known by various names like aerosol nebs, usually holds about 6 mL of solution.

    • Critical for delivering multiple medications, such as albuterol and Atrovent, mixed with saline.

  • Valve Holding Chamber (Spacer):

    • Assist in coordinating inhaler use and maximizing medication delivery.

    • Prescribers need to order it separately.

Bronchodilator Medications

  • Main Bronchodilators:

    • Albuterol:

    • Standard dose for MDI: 90 mcg; nebulizer: 2.5 mg.

    • Typically used in a total solution of 3 mL.

    • Ipratropium (Atrovent):

    • Nebulizer dose: 0.5 mg.

    • An anticholinergic paired commonly with beta-2 adrenergics.

    • Levalbuterol (Zopanex):

    • Dose: 1.25 mg, with a possible half dose of 0.63 mg.

    • Beta 2 bronchodilator

  • Combination Treatments:

    • Albuterol and Ipratropium or Levalbuterol and Ipratropium for improved response in acute management.

Administration Techniques and Guidelines

  • The advantages of aerosolizing medications compared to systemic administration:

    • Faster effects, smaller doses, and reduced side effects.

  • Potential Hazards:

    • Common side effects include jitteriness and tachycardia due to stimulation of both beta and alpha receptors.

    • Risk of bronchospasm if concentration or delivery method is poor; proper cleanup of equipment is essential to prevent infections.

  • Eye Irritation:

    • Anticholinergics can lead to pupil dilation, especially concerning in cases where patients might inadvertently get medication in the eye.

Mucoactive and Corticosteroid Medications

  • Mucoactive Drugs:

    • Dornase Alpha (Pulmozyme): For cystic fibrosis patients, helps in thinning mucus (cost: ~$4000).

    • Acetylcysteine (Mucomyst): In two formulations (10% or 20%).

    • Hyperosmolar Saline: 7% saline solution used for sputum induction and treating thick secretions.

    • Mucoactive

  • Corticosteroids:

    • Various inhaled corticosteroids such as beclomethasone and budesonide for asthma and inflammation control.

    • Must be rinsed from the mouth post-administration to prevent thrush.

  • Combination Inhalers:

    • Newer triple-combo inhalers target chronic conditions like COPD.

    • Example: Trelegy containing corticosteroid, long-acting bronchodilator, and anticholinergic.

Clinical Considerations

  • Baselining Patient Medications:

    • A thorough medication history is vital. Know about concomitant medications affecting treatment efficacy (e.g., beta blockers).

  • Aerosol Dosage and Monitoring:

    • Continuous therapy may lead to potassium deficits; regular monitoring is advisable.

  • Patient Teaching:

    • Importance of using spacers, priming inhalers, understanding drug action, and potential side effects.

  • Drug Cost Implications:

    • Highlighted issues with high-cost versus generic medications and the impact of insurance on accessibility.

  • Future of Drug Delivery:

    • Innovations such as electrically powered nebulizers may improve delivery efficiency and patient outcomes.

Conclusion and Clinical Practice

  • AARC guidelines are fundamental for respiratory therapies; continuous learning and questioning during clinical practices are encouraged for a thorough understanding of treatment efficacy and best practices in patient care.