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Wednesday, May 26, 2010

Emergency Room RT Consult

The following is an ideal emergency room RT Consult, or aerosolized medication protocol for ER, that we have been working on. If anyone has suggestions to make this even better, please feel free to suggest.

For a printable copy of this protocol, click here.


Protocol Content:

1. Scope: A Licensed Registered Respiratory Therapist (RRT) or Certified Respiratory Therapist (CRT) who has successfully completed and passed all competencies related to patient assessment and protocols. Although respiratory students and assistants may perform medicated aerosol therapy, they may not adjust therapy per protocol.

2. Emergency Room Aerosolized Medication Protocol

A. When a physician, physician’s assistant, RN, or RT orders RT Consult or RT to assess and treat, the RCP will be paged for a RT Consult. The RT may initiate this protocol working within the following guidelines.

B. Upon receiving the order, the respiratory therapist will assess patient and select appropriate therapy and medication.

C. The following conditions are accepted indications for bronchodilator therapy:

  • a. Bronchospasm/ wheezing
  • b. Asthma/ reactive airway disease
  • c. Diminished lung sounds
  • d. COPD
  • e. Prolonged expiratory phase
  • f. Obstructive defects of PFT
  • g. Impaired mucous clearance

D. B. Medications available per protocol:

  • a. Albuterol 0.25-0.5cc
  • b. Duoneb 1 unit dose vial
  • c. Atrovent 1 unit dose vial
  • e. Xoponex 0.63-1.25mg
  • f. Albuterol MDI

E. The following assessment and chart findings will be evaluated and documented as appropriate:

  • a. Vital signs (HR, RR, BP)
  • b. Current FiO2
  • c. Pulse oximetry
  • d. PEFR (if indicated)
  • e. Patient assessment results (lung sounds, work-of-breathing, cough, secretions)

F. Peak Expiratory Flow Rates (PEFR) will be done on asthmatics before and after the initial treatment according to the patient’s tolerance to perform the maneuver, or this will be performed as soon as patient is able.

G. Following an initial assessment, an initial treatment will be given to patient’s who meet the indications for therapy. If patient does not demonstrate improvement in PEFR, relief in Dyspnea or reduction in expiratory rhonchi or wheezing, the treatment may be repeated. If necessary, a third treatment may also be given.

H. If there is no improvement after repeated treatments, the physician will be informed the patient is not responding to therapy. Further therapy will be given only with physician notification.

I. If respiratory therapy determines patient would benefit from a MDI bronchodilator for home use, and the patient meets the criteria for MDI use, an Albuterol MDI may be administered to patient, and patient will be instructed on correct use of this MDI. The recommended dose and frequency is Q4-6 hours as needed.

J. Criteria for MDI use:

  • 1. Can physically perform the maneuver.
  • 2. Can follow directions.
  • 3. Is cooperative and alert.
  • 4. Can take a slow deep inspiration.
  • 5. Can hold breath for at least five seconds.
  • 6. Is able to perform a return demonstration.
  • 7. Respiratory rate less than or greater than= 25

3. Documentation:

A. Initial Assessment:

1. The respiratory therapist will write the order in the patients chart including medication, dose and frequency per RT Consult if the ordering physician did not already do so.

2. Initial orders written by the physician do not have to be rewritten by the respiratory therapist unless clarification or adjustments are required.

3. All therapy will be documented in the computerized charting system.

B. Re-assessments:

1. All patients will be assessed with every treatment to determine the patient’s current pulmonary status and effectiveness of the aerosol therapy.

2. Adjustments of the patient’s therapy will be determined objectively by changes in the monitored parameters.


1. Spectum Health (2005) Aerosolized Medication Protocol, Grand Rapids: Spectrum Health.

2. Northern Michigan Hospital (2004) Bronchodilator Protocol, Petosky, MI: Northern Michigan Hospital.

3. Covenant Health Care (2005) Respiratory Therapy Consult, Saginaw, MI: Covenant Health Care.

4. “Guidelines for Preparing a Respiratory Therapy Protocol.” Retrieved August 23, 2007, from
5. “Respiratory Therapy Protocols.” Retrieved August 4, 2007, from

Word of the dayAttenuate: To make thinner or weaker; to make slender; to rarify; to enervate

A few stupid doctor's orders is all it takes to attenuate my energy supply.


Anonymous said...

Why the criteria for MDI use? Everyone can use an MDI even if by mask, including pediatric patients. I would also suggest that just about all patients get up to 3 albuterol/atrovent nebs in ER. Hardly anyone should just get albuterol alone. Good luck...

Anonymous said...

Please explain why you think a person should receive 3 back to back doses of atrovent? And why albuterol shouldn't be given alone.
We have ER docs in our hospital that give atrovent x3 and I think it's ridiculous. What benefit are you receiving? I've asked them for evidence to show what benefits this gives but have never received any info back.

Rick Frea said...

Here is a post I wrote about the latest wisdom about atrovent. After reading these you might get a better understanding why Atrovent is being ordered so much in the ER. Usually, however, Atrovent is given in conjunction with Albuterol (Duoneb). We do have some doctors who given every treatment with Duoneb, even continuous.

I can think of no reason to just give Atrovent treatments, unless perhaps the doctor believes Atrovent will dry secretions. I think there is some evidence it does that, however the research is kind of mixed on that.

I am with you in that I see no benefit from giving Atrovent treatments alone. I would imagine the reason your doctors aren't providing the evidence is because there is none. However, keep bugging them and if they do provide the evidence please let us know by placing a comment here with your new wisdom about Atrovent.

Anonymous said...

I think you should give the MDI either QID,OR Q4W/A WITH Q4PRN added on.I cant see waking patients up at 2 or 4am for an MDI unless they having trouble breathing.That way a patient can get the needed rest.Patients can have trouble doing the MDI correctly when they are dead tired.