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Monday, November 12, 2012

When do you end a breathing treatment?

A question of much debate in the respiratory therapy community is when to end a breathing treatment.  Many hospitals have a policy that the treatment should last up to ten minutes, while others contend it takes less than five.

Some respiratory therapists, and many patients, tap the nebulizer until they presume all the medicine in the cup is gone, while others simply end it once the medicine in the nebulizer cup starts to sputter.  So who is right and who is wrong?  Is tapping necessary?

According to the experts a breathing treatment ends when the medicine starts to sputter, and by this time most of the medicine is gone.  This was discussed by Dr. Bruce Rubin and James Fink, RRT, in their 2003 article"The delivery of inhaled medication to the young child," in Pediatric Clinical of North America (50, pages 717-731).  They write:
Most of the available medication in the nebulizer cup is nebulized in the first
few minutes [10]. All nebulizer cups have some amount of medication remaining
near the end of therapy, when aerosol generation becomes intermittent. This
intermittent nebulization is referred to as sputtering; it has been documented that
aerosol delivery to the patient declines by half within 20 seconds of the onset of
sputtering [13]. At this time it is appropriate to discontinue therapy.
Accordingly, the the study showed that (2, page 316):
Albuterol delivery from the nebulizer stopped with the onset of inconsistent nebulization (sputtering).  Continuation past the past the point of jet nebulizer sputter is ineffective and should indicate an end of the treatment.  
So there you have it.  Now you know when is the best time to end a treatment.

Further reading:
  1. Rubin, Bruce K, M.D., James B. Fink, RRT, "The delivery of inhaled medication to the young child," Pediatr Clin N Am 50 (2003) 717– 731.  Note:  James Fink is one of the foremost experts on aerosol delivery and has been involved in many tests and written many articles on the subject.  You should Google him to see what else he has written.  You might be impressed.
  2. Hess, Dean, Neil MacIntyre, Shelley Mishoe, William Galvin, editors, "Respiratory Care Principles and practice," 2nd edition, 2012, Jones and Bartlett, page 316


Phoenix Fire Falconry said...

Cool! I've been doing it fairly correct. I usually start a watch, and usually reply it takes "about 7 minutes" with the neb cups we use and the pressure from the wall. I do tap it a couple times as it starts to sputter. Nice to know . . . Thanks for the share!

Rick Frea said...

I never tap. When it's done it's done. If the patine insists, he usually does it himself. I've never had a problem with this policy.

Rick Frea said...

Patine? What's a patine? I meant patient.

Unknown said...

I always tap it down. I feel like the customer should get their moneys worth, and most COPD'rs prefer it that way. Who am I to argue? I remember when my mom (with COPD) was in the hospital, and the RT ran her med neb at a high flow, 8-10 LM. This created a very dense mist initially, which made her reactive airways more sensitive and actually put her INTO more bronchospasm, as well as blew most of the meds right past her. The tx. was done in less than 5 min.. Good for the RT, he was done and moved on to his next patient, but mom got very little benefit from the tx.. I run the neb slower, at 6LM, until their airways are less sensitive and they can actually breathe the meds in, then kick it up to 8 towards the end to finish it. Yes, I'm there longer, but I'm there to help the patient, not just knock out tx.s!!

Unknown said...

My post triggered another thought/questin for me. How fast/at what flow do you run your med nebs?

And can I just say how much I LOVE the aerogen for in-line treatments on vents? Doesn't add flow to the system, which is GREAT for our Servo, Jet and HFO vents, great particle size.