Evidence-Based Nursing

Step 1:

Step 2: Step 3: Step 4: Step 5:

(> 50 %)

/ /

(> 80 %)

(Aerosol Therapy) (2002 )

,,

,

, ,,

O2 flow 6-8 l/min,

,

45-90, ,,

15

, , ,

,

Inhalation

Evidence-Based Clinical Practice GuidelinesBrochiolitis

(level D)

suction(level D)

CPT(level Ib / Level D)

Cool mist therapy (level D)

Saline aerosol therapy.. (level Ib)

EBN

/

O2 flow

flow, ,

,

/

Step 1: Step 2: Step 3: Step 4: Step 5:

Step 1:

Patient

Outcome

Comparision

Intervention

1

(next)

V.S 0.9%

pneumonia, Bronchopneumonia()

7

/ (/ )

()

2

() ( Jet Nebulizer )

(2002 )

(Bernoullis priniciple),, , , 2~5

(, 2001; Uma Maheswari, 2001 )

,,

3

(1)

(2002 )

,

(2)

(Aerosol Therapy) 2

(2002 )

,

,

,:

(3)

(Aerosol Therapy) 3

(2002 ; Uma Maheswari, 2001 )

,, (Aiwway obstruction)

(Bronchospasm)

(Over hydration) ,

(Infection)

,(Thermal injury)

(4)

< 3um

(jet nebulizer) vs.

()

(2002 )

(5)

> 2um

O2 mask

35 %;15 %

(6)

< <

Step 2:

http://www.wanfang.gov.tw/EBM/

1

aerosol therapy (1)

0

nebulizer ( )

0

steam inhalation (6)

0

2

aerosol therapy (40)

1

nebulizer (40)

1

steam inhalation (1)

1

3

aerosol therapy (18)

3

nebulizer (77)

2

steam inhalation (1)

0

MEDLINE

4

aerosol therapy (1268)

2 ( 451)

inhalation (6)

0

Step 3:

,

The Evidence Pyramid

()

--US Agency for Health Care Policy and Research Classification (AHCPR, 1992)

(Grades of Recommendation of Effectiveness )

Develop by JBI

(1-1)

(2001), 42, 50-55

(1-2)

(, 2001)

Gas flow rate: 6~8 l /min

Nebulizing volume: 4~5 c.c.

Slow and deep breathing pattern

Mouth breathing better than nose breathing

IV

(2-1)

(Aerosol Therapy)

(2002), 1(1), 81-101

(2-2)

, ,

IV

(3-1)

AEROSOL THERAPY

Uma Maheswari

Pulmonary & Critical Care Bulletin

Vol. VII, No. 3, July 15, 2001

(3-2)

Bland aerosols include heated or cooled sterile water and saline.These aerosols are mainly used in treatment of upper airway disease, humidification of the bypassed airway and sputum induction.

(3-3)

Higher flow rates cause turbulent flow, aerosol fragmentation and failure of deposition.Higher respiratory rates are associated with higher flow rates and poor aerosol deliveryHence a slow, deep breath with an end inspiratory breath - hold of 5-10 seconds is optimal for aerosol impaction in the bronchi and bronchioles.

(3-4)

Gas flow rates of 6-8 lpmOptimal volume of nebulising solution : 4-5 ml Particle size : 1-5 u 10% of aerosol reaches its site of action

Evidence Grade D

(4-1)

Evidence based clinical practice guidelines for the infant with bronchiolitis.

Cincinnati Children's Hospital Medical Center.

Evidence based clinical practice guideline for infant with bronchiolitis. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2001 Nov 28. 9 p.

(4-2)

Scheduled or serial use of bronchodilator aerosol therapies is not recommended unless there is a documented clinical improvement response from a given patient

Inhalations using epinephrine as a trial therapy may be considered

if, between 15-30 minutes after a trial inhalation therapy, there is no significant improvement in clinical appearance, it is recommended that the therapy not be continued nor be repeated.

(4-3)

It is recommended the infant be suctioned before feeding, PRN and prior to each inhalation therapy (Evidence Grade E).

Suctioning itself may improve respiratory status such that inhalation therapy is not necessary. Thus, it is important to document the pre-and post-suction score.

Suctioning may improve the delivery of the inhalation treatment (Evidence Grade E ).

Normal saline nose drops may be used prior to suctioning (Evidence Grade E ).

(4-4)

Other routine respiratory care therapies are not helpful and are not generally recommended.

Chest physiotherapy (CPT) is not recommended (Nicholas et al., 1999 [B]; Webb et al., 1985 [E]).

Cool mist therapy is not recommended (Gibson, 1974 [E]).

Aerosol therapy with saline is not recommended (Chowdhury et al., 1995 [A]; Gadomski et al., 1994 [A]; Ho et al., 1991 [B]).

(5-1)

Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee.

Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R.

MMWR Recomm Rep2004 Mar 26;53(RR-3):1-36.

(5-2)

Between treatments on the same patient clean, disinfect, rinse with sterile water (if rinsing is needed), and dry small-volume in-line or hand-held medication nebulizers (IB) .

Use only sterile fluid for nebulization, and dispense the fluid into the nebulizer aseptically (IA).

Whenever possible, use aerosolized medications in single-dose vials. If multidose medication vials are used, follow manufacturers instructions for handling, storing, and dispensing the medications (IB).

(6-1)

Nebuliser hood compared to mask in wheezy infants: aerosol therapy without tears!

I Amirav, I Balanov, M Gorenberg, D Groshar and A S Luder

Archives of Disease in Childhood. 88(8):719-23, 2003 Aug.

(6-2)

Both treatments provided similar clinical benefit and side effects as reflected in improved oxygen saturation, reduced respiratory frequency, and increased heart rate.

It is much better tolerated by infants and preferred by parents.

Hood nebulisation is a simple and patient friendly mode of aerosol therapy in wheezy infants.

Ib

(7)

Effect of ipratropium bromide and/or sodium cromoglycate pretreatment on water-induced bronchoconstriction in asthma.

Tranfa CM. Vatrella A. Parrella R. Bariffi F.

European Respiratory Journal. 8(4):600-4, 1995 Apr.

(7)

ipratropium bromide (80 ug)sodium cromoglycate (20 mg)distilled water bronchospasm

Rrandomized, placebo-controlled, double-blind study (N=15).

measured by change in specific airways conductance (sGaw)

These results suggest that water-induced bronchoconstriction is deterimined by more than one mechanism

Ib

,

Flow

Diluents

, ?.

??

Diluents 1

0.9 % NaCl

bronchospasm, asthma attack

0.45 % NaCl

3 % NaCl

Distill Water

bronchospasm

Diluents 2

0.9 % NaCl

bronchospasm

bronchodilator

Distill Water

bronchospasm

bronchodilator

2005.03.0.45% Normal Saline Solutioninhalation solu.

0.45% N.S. Solution,

< 5 u

?

O2 mask vs O2 hood / tent ?

O2 hood / tent , ,

,

Atrauma care!

Aerosol Medication Delivery

http://www.wanfang.gov.tw/EBM/ebn/vision.htm

!