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11310 hope nebulizer 1208


Respiratory Care Services Policy and Procedure Manual

Policy and Procedure Title:
HOPE™ Continuous Nebulizer Protocol
Area: Respiratory Care Services
Performed by: Respiratory Care Practitioners
Policy Number:
Approved by:
Current Effective Date
Approved by:
Review Date
Approved by:
Revised Date
Approved by:

This policy assures the standardized use of the HOPE Continuous Medication Nebulizer for use in
the delivery of aerosolized medications and diagnostic formulations with a 230 ml reservoir.
The purpose is to provide for an easily implemented protocol to be used by the Respiratory Care
Practitioner with effective guidelines and consistent instruction for use in the delivery of continuous
nebulization to patients that are in a closely monitored area in the hospital.
The HOPE Nebulizer is a high output nebulizer to be used to deliver aerosolized medication and
diagnostic formulas. It provides additional hydration to help loosen secretions for patients whom
therapy is indicated. Heliox, air or oxygen may be added via the multi gas inlet.

To ensure patient safety the device is intended to be used under medical supervision in the hospital,
emergency department, extended care and inpatient and outpatient clinics.
Provide Long term bronchodilation for patients with serious Asthma, Exacerbation of COPD, B&B HOPE™ Continuous Medication Nebulizer Policy and Procedure ● 2008 B&B Medical Technologies EQUIPMENT
B&B HOPETM Nebulizer
(P/N 11310), Oxygen and/or medical grade air at 50 psi, Blender, Oxygen
Analyzer with Alarm, Aerosol Tubing, Mask or other delivery device, Cardiac monitor (if indicated)
and Pulse Oximeter (if indicated). The B&B Heliox regulator (P/N 11370) can be used for the
delivery of 80/20 Helium-Oxygen Gas Mixture.

A: Application/Preparation Steps
Therapy should be initiated in the ER, Critical Care Unit, and Pediatric Critical Unit or in an area in which the patient's EKG may be monitored continuously. After an order has been received, the therapist is to verify the order in the patient's chart. The treatment must be reordered every 24 hours by a physician. After checking the patient's ID, the therapist is to explain the procedure to the patient and answer any questions the patient may have. Wash hands and assess patient's heart rate, breath sounds, respiratory rate, peak flow, color, use of accessory muscles, patient's oxygen needs (current ABG) or Sa02. Set up a continuous pulse oximeter to establish baseline saturation and monitor the patient. Attach the HOPE Nebulizer to the flowmeter or blender (Figure 2). Attach the corrugated tubing to the HOPE nebulizer output and to the aerosol mask or other B: Application/Action Steps
PREPARE MEDICATION per protocol of this policy (Section E). Pour medication into the HOPE nebulizer reservoir using aseptic technique. Set flow meter to 10 liters per minute and adjust Fi02 per chart or Blender to meet patient needs after attaching appropriate size mask to the patient. Monitor the patient for adverse reactions and check the HOPE nebulizer every 30 minutes x To determine approximate use of medication, look at the marks on the side of the nebulizer (marks on nebulizer are in 25 ml increments). Adjust the flowmeter by small increments to achieve desired output of 25 ml/hour, without auxiliary flow. When using auxiliary flow output increases. Mix one more hour of medication to
C: Application/ Patient Assessment
Monitor the patient’s Pulse before, during treatment, every 30 minutes x 2 hours, then Assess Breath sounds before, during and post treatment. Assess patient with Pulse oximeter before, during and post treatment. In pediatrics, a TCM may be used to monitor patient pre, during and post treatment to Measure Peak Flow rates before treatment, during treatment every hour x2, then every 2 Document Subjective statements by patient. Monitor and document patient position, color and level of cooperation. Monitor and document complications or problems noted during therapy. B&B HOPE™ Continuous Medication Nebulizer Policy and Procedure ● 2008 B&B Medical Technologies Measure and monitor Electrolyte levels at physician discretion, if patient is receiving agonist Reevaluate the patient after initial 2 hours of therapy for possible decrease in drug
D: Documentation/Charting
Check the patient and document the following information every 30 minutes for the first 2 hours, then every 2 hours on the Patient Flow Sheet
E: Prepare Medication Protocol
This protocol is a guide to the preparation of medication. Physician orders as to medication content
and strength must be on the chart prior to start of Continuous Bronchodilator Nebulization Therapy
(CBNT). It is inherent to this therapy that the patient may need to have the dosages changed several
times after the initiation of this procedure. The therapist must be aware of the signs that indicate the
need for dosage change and alert the physician to any change in the patient's status.
Guidelines based upon the dosing chart included with the HOPE Nebulizer:
Initial Gas flow consideration is 10 lpm of 100% source gas driving the nebulizer The medication delivery is based on physician prescription for mg/hr or ml/hr of Mg/hr of medication ordered x 0.2 = ml of medication used per hour. Output of nebulizer - ml of medication = ml of diluent (normal saline) Multiply diluent and medication times hours you want to deliver; up to 8 hours @ 10 lpm (maximum volume of nebulizer is 220 ml).
Instruction Sheet.
This is a sample calculation. Ideally, when setting up CBNT, the initial fill and
dosage should be for 3 hours.
MEDICATION + DILUENT = OUTPUT OF NEBULIZER (25 ml/hr. @ 10 lpm) Albuterol 0.5% (5 mg = 1 ml, 10 mg=2 ml, 15 mg=3 ml, 20 mg=4 ml) Dosage recommendations

B&B HOPE™ Continuous Medication Nebulizer Policy and Procedure ● 2008 B&B Medical Technologies The use of other than the above bronchodilators for the CBNT for severe bronchospasm should be reviewed by the physician in regards to the following criteria. The ideal drug for this form of therapy has high efficacy with side effects which are both infrequent and benign. The drug may not have metabolites, which are bronchoconstrictors. The pulmonary deposition of drug is dependent upon the following: A. The drug concentration in the aerosol mist. The patient's minute volume and respiratory rate. Other physical factors such as the inspiratory flow rate, airway diameter and route of
Initially, patients with severe bronchospasm may have reduced tidal and minute volumes, as well as
decreased airway diameters. The reduced volumes in combination with high inspiratory flow rates
and narrow airways can lead to a marked reduction in the amount of drug deposited in the lungs. In
this situation, a stronger dose is needed to achieve bronchodilation. High doses may lead to side
effects as the patient "opens up". When the patient improves, their minute volume and airway
diameters may increase and their inspiratory flow rates decrease. The resulting increase in the
amount of drug being deposited in the lungs may lead to side effects such as nausea, vomiting,
tachycardia and a decreased electrolyte levels (K+ in particular). To avoid this, the patient should be
reassessed often and the dose reduced as improvement is noted.

F: Contraindications:

Increased heart rate of >25 beats or as defined by the physician.
G: Treatment Complications:
A complete reassessment is indicated any time the patient vomits. Failure may include, but is not
limited to the following:
Failure to significantly respond in 4 hours. Decreasing aeration over time or increased wheezing without a simultaneous increase in Decreasing pulse oximeter readings or an increasing need for higher Fi02’s to maintain the Anything that leads you to believe, through your patient assessment, that the patient is When treatment failure is suspected, re-evaluate the patient and contact the physician
H: Precautions and Adverse Events
Exhaled aerosol or patient coughing may spread active pulmonary infections. The HOPE Nebulizer is intended for single patient use. B&B HOPE™ Continuous Medication Nebulizer Policy and Procedure ● 2008 B&B Medical Technologies PROCEDURE

IMPORTANT: Use oxygen analyzer to verify Fi02
IMPORTANT: Auxiliary flow increases nebulizer output, mix one more hour of medication.

A. Heliox Therapy
Using 80/20 Heliox: 50% Fi02 50% Helium
Set the Primary gas delivery at 10 lpm oxygen. Auxiliary gas 80/20 Heliox at 17 lpm or 15 lpm on the B&B Medical preset Heliox regulator For every hour of medication delivery, mix 2 hours of solution. Use alarmed oxygen analyzer to titrate nebulizer output to 50% Fi02.
IMPORTANT: Use oxygen analyzer to verify Fi02
IMPORTANT: Auxiliary flow increases nebulizer output, mix one more hour of medication.
B. Guidelines for Auxiliary Flow and Nebulizer Output
With the addition of auxiliary flow (lpm), the out put of the nebulizer increases. The Hope Output
Chart provides guidelines with average output in ml per liter of gas delivered to the patient. This
chart provides the approximation of change in time for delivery of the medication along with average
output of the medication delivered to the patient.
B&B HOPE™ Continuous Medication Nebulizer Policy and Procedure ● 2008 B&B Medical Technologies Source Gas
Auxiliary Flow
Hope Nebulizer
B&B HOPE™ Continuous Medication Nebulizer Policy and Procedure ● 2008 B&B Medical Technologies Reference Articles: Continuous Medication Nebulization Therapy

Moler FW, Hurwitz ME, Custer JR. Improvement in Clinical Asthma Score and PaCO2 in ` Children with Severe Asthma Treated with Continuously Nebulized Terbutaline. J Allergy Clin Immunol 988; 81:1101-1109 Portnoy J, Aggarwal J. Continuous Terbutaline Nebulization for Treatment of Severe Robertson CF, Smith F, Bech R, Levison H. Response to Frequent Low Doses of Nebulized Schuh S, Parker P, Najon A, Carry G, et al. High versus Low Dose Frequency Administered Nebulized Albuterol in Children with Severe Acute Asthma. Thivierge BM, et al. Effects of continuous inhalation of Salbutamol in Acute Asthma. Calacone A, et al. Continuous Nebulization of Albuterol in Acute Asthma. Chipps BE et al. Vortran High Output Extended Aerosol Respiratory Therapy (HEART) for delivery of Continuously Nebulized Terbutaline for the Treatment of Acute Bronchospasm. Pediatric Asthma, Allergy & Immunology 1990; 4: 271-277 Standing C, McCoy K, Hoppe M. Continuous vs Intermittent Aerosolized Albuterol in the Pediatric Emergency Care 1989; 5 (4): 289 (abstract) Bodenhamer J et al. Frequently Nebulized Beta Agonists for Asthma: Effects on Serum Rudnitsky G, Spivey WH et al Comparison of Intermittent and Continuously Nebulized Albuterol for Treatment of Asthma in a Urban ED. (Abstract) Colacone A, Wolkove N et al. Safety and Efficacy of Continuous Nebulization of Salbutamol in Initial Emergency Treatment of Asthma. Am Rev Respir Dis 1989; 139 (4): a-431 (abstract) Lin, R.Y. et al. Continuous versus Intermittent Albuterol Nebulization in the treatment of Papo MC MD, et al. A Prospective, Randomized Study of Continuous Versus Intermittent Nebulized Albuterol for Severe Status Asthmaticus in Children. Fink JB, Dhand R. Secondary flow of air and Heliox through a closed dilution nebulizer improves bronchodilator delivery. Respiratory Care 1998; 11 Fink JB. Helium-Oxygen: An Old Therapy Creates New Interest. Journal for Respiratory Care Practitioners 1999; April/May: P-71 Lu TS et al. Helium-oxygen in upper airway obstruction. Anesthesiology 1976; 45:678-680 B&B HOPE™ Continuous Medication Nebulizer Policy and Procedure ● 2008 B&B Medical Technologies


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