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Purpose:
To provide protocol driven respiratory therapy to treat reversible airway obstruction in patients who do not improve
after the administration of the "standard dose" as specified in the Small Volume Nebulizer Protocol. Therapeutic
Effective Dosage is an extension of the Small Volume Nebulizer Protocol.
Scope:
Practitioner (RCP) members of the Respiratory Care Department with successful demonstration of Patient Driven
Protocol (PDP) skills.
Policy:
1) The Therapeutic Effective Dosage Protocol will be initiated on patients by a written order from the physician for
a therapeutic effective bronchodilator dosage if the patient is incapable by virtue of physical or cognitive impairment
to administer an MDI, or if the medication prescribed is not available in the MDI form. The Therapeutic Effective
Dosage Protocol may be ordered as:
- therapeutic effective bronchodilator- therapeutic effective aerosol- RT Protocol- RT Consult In addition, the Therapeutic Effective Dosage Protocol may be ordered specifically and in other forms other thanspecified by this protocol by writing an order that specifies the drug, dose and frequency.
After the physician has written an order, a qualified RCP will: - Evaluate the patient upon receipt of the physician's order- Transcribe the plan in the physician's order section of the medical record, label the entry as "PDP" andinclude their signature and credential.
- Document all treatment times and changes in medication dosage and/or frequency on the MAR form.
2) If the patient is not a candidate* for a MDI and the physician desires to order an aerosol dose level outside the limits of the Therapeutic Effective Dosage Protocol, the M.D. will write: - an order for a specified drug dose- a frequency- a statement that the RT Protocol is not to be initiated * If the patient is a candidate for a MDI, bronchodilator therapy via a small volume nebulizer can only be initiated ifthe therapy has been approved by the medical director of Respiratory Care. In the event that the medical director ofRespiratory Care can not be reached, the medical director of each unit/service has the authority to approve thebronchodilator therapy via a small volume nebulizer on a case by case basis.
-deliver the treatment as ordered-evaluate the patient-contact the physician for any indicated modification in the Rx regimen If the PDP recommendation is not in accord with the physician's request: -the therapy rationale and desired outcomes of the therapy will be documented in the progress noteswithin 24 hours.
-the RCP may place a therapeutic objective sticker in the progress notes to help facilitate the physician'sdocumentation.
Equipment:
mhtml:file://C:\Documents and Settings\All Users\Documents\CRT-Book\protocols\UCSD_protocol. 2/7/2010 -oxygen flowmeter with nipple-oxygen connecting tubing-hand held nebulizer-mouth piece or mask-peak flow meter or Renaissance Spirometer-medication (Albuterol/Atrovent or prescribed medication)-MDI with spacer Overview:
The RCP will perform a PDP patient evaluation, identify any contraindications or hazards, and apply the Clinical
Practice Guidelines for the Therapeutic Effective Dosage Protocol.
The principal goal of treatment is for the rapid relief of reversible airflow obstruction by titrating higher dose levelsof adrenergics and combining anticholinergic therapy. Such patients are considered to have moderate to severechronic airflow obstruction. The severity of airflow obstruction cannot be accurately judged by patient symptomsand physical examination alone. Measurements of airflow obstruction (by spirometry or by peak flow meter) are anintegral part of the assessment of disease severity and of the response to therapy.
Reversal of airflow obstruction is most effectively achieved by the repetitive administration of beta2-agonistbronchodilators early in the course of exacerbation. Inhalation of therapeutic bronchodilators has been shown toeffectively treat airway obstruction. In addition, aerosolized drugs have a rapid onset of action with fewer systemicside effects, however, their effects are shorter lived as they are degraded in the lung, cleared by the mucociliary tractas well as absorbed in the blood and metabolized.
The objective of such therapy is to decrease airway resistance thus improve the distribution of ventilation, improveV/Q, minimize the mechanical disadvantages of prolonged expiratory airflow, and decrease the patients work ofbreathing. A bronchodilator will not likely accomplish these important objectives if the patients airway obstructionis not the result of bronchospasm.
If the patient is incapable by virtue of physical or cognitive impairment to administer an MDI or has proceeded fromthe Small Volume Nebulizer Protocol, the RCP will initiate an aerosol treatment with 1cc of Albuterol and 2 ccnormal saline. An equal amount of Atrovent should be added to treatments for COPD patients, however Atrovent isnot available in undiluted form, therefore .5 cc of Atrovent and 2.5 ml of NS will be given. If the physician choosesto use another drug solution, the RCP will convert the patient to the proper dose. If there is no improvement, thetherapy can be repeated up to two times in 20 minute intervals. If there is no improvement after repeating thetherapies, the physician and R.N. will be notified and informed that the patient is not responding to therapy. At thistime the RCP can consult with the physician and suggest that other Respiratory medications be implemented ordiscuss an alternative pharmacological plan.
If improvement is noted after receiving the first Albuterol or after the patient received the series of treatments, thepatient will continue on therapy with the determined *therapeutic dosage level Q-4 hours and Q-2 hours PRN.
*The Therapeutic Dosage level is the amount of drug given up to this point.
1st treatment = 1 cc of Albuterol (.5 cc of Atrovent for patients with COPD) 2nd treatment = 2 cc of Albuterol (1 cc of Atrovent for patients with COPD) 3rd treatment = 3 cc of Albuterol (1.5 cc of Atrovent for patients with COPD) PRN treatments are appropriate when moderate to severe symptoms reoccur within the 2 hour period. The physicianand R.N. should be notified if the patient continues to require PRN treatments . When the peak flow or FEV1 isgreater than 15% of baseline (personal best or predicted, as determined by the clinician) the therapeutic dose will betapered within a 24 hour period. If FEV1 or peak flows are below 15% of baseline, patients will continue on Q-4hour treatments without tapering their dose.
A re-evaluation will be completed every 24 hours. If symptoms are not resolved after the patient has been tapered toa normal dose, the physician will be notified to increase the medication to maintain the peak flow or FEV1 level. Thephysician will also be contacted if the patient continues on therapy for more than three days.
MODERATE
LIFE THREATENING
mhtml:file://C:\Documents and Settings\All Users\Documents\CRT-Book\protocols\UCSD_protocol. 2/7/2010 RESPIRATORY
It is imperative for the RCP to identify the severity of the patients illness. Patients with persistent respiratory distressand a PCO2 that continues to rise despite appropriate therapy are at risk for respiratory failure. In general, intubationand mechanical ventilation are indicated to those patients whose PCO2 exceeds 50mm Hg and continues to risedespite therapy. If the RCP notes contraindications, observes an adverse response, or the patient fails to respond totherapy the responsible physician and R.N. will be immediately informed.
Pulmonary Considerations:
Contraindications:
-acute cardiac arrhythmia (eg, ventricular ectopic activity or tachyarrhythmia)-known sensitivity to a specific medication -cardiac arrhythmias
-worsening hypoxemia
-tachycardia
-acute hypertension
-tremors
-transmission of infections
-pneumothorax from hyperinflation
Guidelines and Warnings:
The responsible physician and R.N. should be contacted:
-if the RCP is unable to determine appropriate care upon evaluation.
-if the patient demonstrates an adverse response-if there is failure to achieve therapeutic objectives within time frames.
All therapies will be administered in compliance with approved RT policies for that procedure.
Boundaries/Interactions:
The RCP may initiate and discontinue the therapeutic effective dosage protocol as per the clinical practice
guidelines for RT. Modalities outside the limits of the protocol requires a physician order. The RCP will notify the
nursing staff of any acute changes in the patients condition. They will also inform nursing if an increase in pain
medication is necessary to proceed with the therapy.
Related Protocols:
Meter Dose Inhaler Protocol, Volume Reduction Lung Surgery Protocol, Acute Maximum Dosage and Small
Volume Nebulizer Protocol.
Rx Plan:
Upon the completion of the evaluation and after contacting the physician for any indicated modification in the Rx
regimen, the RCP will initiate the Therapeutic Effective Dosage Protocol per the clinical practice guidelines for RT.
The RCP will notify the R.N. regarding the patient care plan.
Documentation:
The RCP will place a copy of the PDP evaluation in the patient’s medical chart and document the provision of all
therapies in CliniVision. If the patient is capable, pre and post FEV1 or Peak Flows should be included to help
determine the efficacy of the therapy. Treatment times and all changes in medication dosage and/or frequency must
be documented on the MAR form.
mhtml:file://C:\Documents and Settings\All Users\Documents\CRT-Book\protocols\UCSD_protocol. 2/7/2010 Outcomes Evaluated:
-Increased peaks flow or FEV1
-relief of dyspnea
-reduction in expiratory rhonchi or wheezing
Justification of DC:
The Therapeutic Effective Dosage Protocol will be terminated when the patient is capable to proceed to the MDIProtocol. Those patients who are incapable of using the MDI with a spacer appropriately will proceed to the SmallVolume Nebulizer Protocol when the medication has been titrated to a normal dose and the peak flows or FEV1 aremaintained.
Re-evaluation:
Patients on the Therapeutic Effective Dosage Protocol will be re-evaluated every 24 hours. If the patient is
discontinued directly from the protocol, a 24 follow-up reevaluation will be completed to assure that an acute
change has not occurred in their condition.
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Source: http://rtboardreview.com/public/web_links/legacy/TED_PDP.pdf